Salivary stones: symptoms, aetiology, biochemical composition and treatment

Submandibular abscess originated from submandibular gland sialolithiasis: a case report

Sialolithiasis, or the formation of stones within the salivary glands, is a common cause of the submandibular gland's duct obstruction, which can lead to submandibular abscesses. We reported the case of a 56-year-old man with a submandibular abscess caused by sialolithiasis of the left submandibular gland. A 56-year-old male patient came with complaints of swelling and pain in the left submandibular area for one week. Patients also reported fever, dysphagia, and increased pain while eating. Physical examination showed diffuse swelling and redness in the left submandibular area. Head MSCT and panoramic radiography revealed the presence of stones in the duct of the left submandibular gland. The patient underwent surgical treatment for stone removal and abscess drainage. Postoperative follow-up showed significant improvement in the patient's condition without complications. If left untreated, sialolithiasis is a primary cause of blockage of the submandibular gland's duct, which can result in infections and abscesses. Prompt and appropriate treatment, including abscess drainage and stone removal, is essential to reduce morbidity. Early diagnosis through anamnesis, physical examination, and imaging are the keys to good outcomes. A submandibular abscess caused by sialolithiasis of the submandibular gland requires quick and appropriate treatment. Surgical treatment with abscess drainage and stone removal provides satisfactory results without complications.

Transoral approach for hilo-parenchymal submandibular stones: outcomes and predictors of success

OBJECTIVE

To evaluate the efficacy and safety of transoral surgical management for complex submandibular gland (SMG) stones.

STUDY DESIGN

A retrospective cohort study of 240 patients treated for sialolithiasis between 2015 and 2018, focusing on 57 cases of SMG stones that underwent stone removal procedures. Treatment methods, success rates, and complications were analyzed using Kaplan-Meier analysis, Cox proportional hazards regression, and multiple logistic regression.

RESULTS

Transoral surgical release was successful in 72.9% of cases. The overall complication rate was 10%. Stone size (hazard ratios [HR] = 0.85, P = .004) and hilar location (HR = 0.72, P = .036) were associated with longer symptom resolution time. Multivariate analysis revealed that stone size (odds ratios [OR] = 0.78, P = .009) and hilar location (OR = 0.45, P = .029) decreased the odds of successful removal.

CONCLUSIONS

Transoral surgical management of hilo-parenchymal SMG stones appears to be a safe and effective approach, potentially reducing the need for sialoadenectomy.

Surgical non-aggressive approach for the delivery of 4 cm salivary stone from the submandibular gland duct: Avoiding salivary gland removal - A case report

INTRODUCTION AND IMPORTANCE

Salivary calculi represent the most common salivary gland disease. It can vary significantly in size, ranging from less than 1 mm to several centimeters. As the size of the stone increases, the surgical approach becomes more complex and the function of the gland may be compromised, potentially necessitating total gland removal. Successful outcomes depend on appropriate indications, precise surgical techniques, and comprehensive postoperative care.

CASE PRESENTATION

A 50-year-old male presented with a chief complaint of pain and swelling in the submandibular region. The patient reported persistent discomfort in the submandibular area for several weeks. Over the last three weeks, his symptoms had intensified, accompanied by an unpleasant taste in his mouth with pain and swelling, especially during meat time. Clinical examination had shown no salivary secretion observed with tenderness across the Wharton duct. Radiological assessment revealed a large salivary stone obstructing the duct of the submandibular gland, the patient underwent surgery under general anesthesia, and an incision was made over the bulge corresponding to the stone. Dissection proceeded through the mucosa until the duct was accessed. The function of the salivary gland was observed, and the return of salivary secretion was confirmed, which was observed immediately after the surgery, and the patient was discharged 5 days after the surgery.

DISCUSSION

The treatment plans for such cases vary between non-invasive conservative management of sialolithiasis, which includes gland massage (combined with the use of sialogogues and irrigation), and advance aggressive management, which may involve extracorporeal shock-wave lithotripsy, sialoendoscopy, or surgical removal.

CONCLUSION

Transoral surgical removal of large stones from the submandibular gland and duct can be an effective and minimally invasive treatment option for sialolithiasis. Proper indications, surgical techniques, and postoperative care are essential for achieving optimal outcomes, minimizing complications, and ensuring successful results.

Microarchitecture and Crystalline Composition: A Comprehensive Exploration of Salivary Gland Stones

OBJECTIVE

To investigate the microarchitecture and crystalline composition of sialoliths and to explore their formation mechanisms.

METHODS

Sixty-six sialolith samples (51 from the submandibular glands and 15 from the parotid glands) were retrospectively collected. Their diameter and quality were measured. Micro-computed tomography, scanning electron microscopy, and polycrystalline X-ray diffractometer (XRD) were utilized to determine their microstructure and crystalline composition.

RESULTS

Stone diameter and weight averaged at 9.6 mm and 0.31 g, respectively. Submandibular stones showed larger size and weight than parotid stones. Microstructurally, the main stones were concentric (n = 51) or mixed (n = 15). Most concentric stones occurred at submandibular glands, while 80% of the mixed stones were parotid stones. Stone surface exhibited three microscopic structures: lamellar, grape-like, and porous, indicating their differences in mineralization process and composition. XRD revealed that all stones contained hydroxyapatite, with 57 containing whitlockite. Concentration of hydroxyapatite in concentric stones was significantly higher than that in mixed stones (p = 0.036) and correlated positively with stone diameter (p = 0.001). The microstructure and crystalline composition of multiple and recurrent stones were similar to that of single stones.

CONCLUSION

Sialoliths display pronounced diversity in microarchitecture and crystalline composition, reflecting the differences in mineralization process and local microenvironments among stones.

A review of the roles of exosomes in salivary gland diseases with an emphasis on primary Sjögren's syndrome

Salivary gland diseases encompass a broad range of conditions, including autoimmune, inflammatory, obstructive, and neoplastic disorders, significantly impacting oral health and overall well-being. Recent research has highlighted the crucial role of exosomes, small extracellular vesicles, in these diseases. Exosomes mediate intercellular communication by transferring bioactive molecules such as proteins, microRNAs, and lipids, positioning them as potential diagnostic biomarkers and therapeutic agents. In primary Sjögren's syndrome (pSS), exosomes derived from Epstein-Barr virus-infected B cells and activated T cells transfer key microRNAs that impair calcium signaling, contributing to glandular dysfunction. Exosome-based biomarkers like Ro/SSA and La/SSB, found in saliva, serum, and tears, offer non-invasive diagnostic tools for early disease detection. Furthermore, mesenchymal stem cell-derived exosomes show promise in treating pSS by modulating immune responses and promoting tissue repair. While exosomes hold promise for the diagnosis and treatment of other salivary gland diseases, such as radiation-induced xerostomia and sialolithiasis, their application remains limited, necessitating further research to unlock their full diagnostic and therapeutic potential. This review focuses on the role of exosomes in salivary gland diseases, with an emphasis on pSS, and highlights the need for future clinical applications and large-scale trials.

Giant Sialolithiasis in Submandibular Gland Growing over Extended Period: A Case Report

Sialolithiasis is a common disease of the salivary glands. This report describes a rare case of a submandibular gland sialolithiasis that grew over an extended period. The patient was a 72-year-old woman who presented with a mass in the right submandibular gland that had remained untreated for approximately 34 years. She had noticed the mass from the beginning, but had ignored it as it had caused no pain. She was eventually referred to our hospital, however, because panoramic X-ray images taken at another facility showed that it had grown over the previous 10 years. Extraoral findings at our clinic revealed a hen egg-sized, elastic, hard mass in the right submandibular region, strongly suggesting intraglandular sialolithiasis of the right submandibular gland. Extraction of the right submandibular gland was performed under general anesthesia. The size of the sialolith inside the submandibular gland was 42×22×15 mm, with a visually rough and yellowish-white surface. Histopathological findings showed a lamellar structure with basophilically stained bacteria in the hard material at the core, a finding typical of sialoliths. Therefore, the diagnosis was intraglandular sialolithiasis of the right submandibular gland. This report describes a case of a rare giant sialolith located within the right submandibular gland.

Streptococcus pneumoniae as a Potential Cause of Pyogenic Parotitis in a Patient with Poor Oral Hygiene and Vitamin D Deficiency

We report an unusual case of recurrent parotitis caused by Streptococcus pneumoniae in a 23-year-old female university student with poor oral hygiene and vitamin D insufficiency. Despite multiple antibiotic courses, symptoms persisted, highlighting the complexity of diagnosis and management in such cases. Diagnostic workup included blood tests, which showed normal inflammatory markers, and magnetic resonance sialography, revealing two intraductal stones in the right parotid gland. Microbiological culture of purulent discharge from the parotid duct identified S. pneumoniae. The patient was successfully treated with levofloxacin, guided by culture sensitivity, along with parotid massage and hydration. Pneumococcal vaccination was recommended as a preventive measure, with no reported side effects after the first dose. This case underscores the importance of considering S. pneumoniae, an uncommon pathogen in immunocompetent adults, as a potential cause of parotitis. It emphasises the role of comprehensive diagnostics, including imaging and microbiology, in managing recurrent parotitis, especially when typical treatments fail. The case also highlights the potential interplay between oral hygiene, vitamin D status, and susceptibility to unusual pathogens in parotid infections.

Factors Precipitating Overnight Admission After Sialolithectomy

OBJECTIVE

To determine factors predicting overnight admission after sialolithectomy.

STUDY DESIGN

Quality outcome database research.

SETTING

The National Surgical Quality Improvement Program American College of Surgeons Participant User Files.

METHODS

Current Procedural Terminology (CPT) codes 42330, 42335, and 42340 between 2007, and 2020 resulted 916 cases. Correlations between perioperative factors and overnight admission (ie, length of stay >0 days) were tested. Cases were stratified into endoscopic (ES) and nonendoscopic (NES) procedures using concurrent CPT codes 42660, 42669, and 42650.

RESULTS

After sialolithectomy, 13.7% (126 cases) were admitted at least overnight. Upon multivariate analysis, wound Class 4 (odds ratio [OR]: 2.15, 95% confidence interval: 1.05, 4.40), American Society of Anesthesiologists (ASA) 3 classification (OR: 2.17, 1.06-4.46, P = .035), and the operative time (OR: 1.01 [1.01-1.01], P < .001) correlated with overnight stay; while Class 2 wounds had a lower risk of overnight admission (OR: 0.31 [0.12-1.63], P < .001). The ES cohort had longer operative times (56.1 vs 73.6 minutes). In the NES cohort's multivariate analysis, ASA III (OR: 2.459 [1.13, 5.34], P < .001) and operative time (OR: 1.01 [1.01, 1.02], P < .001) correlated with overnight stay while Class 2 wound classifications protected against overnight stay (OR: 0.28 [0.15, 0.52], P < .001).

CONCLUSION

This study highlights the correlation between intraoperative complexity, as operative time, wound classification and ASA Class 3, and the need for admission after a typically ambulatory sialolithectomy. The significantly longer operative time with evidence of a shorter length of stay in ES cases suggests a valuable trade off, within the limits of indication.

Influence of clinical experience in detecting calcifications of the head and neck region on panoramic radiographs: an app-based evaluation

Introduction

Digital panoramic radiographs (DPRs) are used in dental practice as the first diagnostic tool for the initial detection of head and neck regions soft-tissue calcifications. The aim of this study was to use a self-developed application (App) to evaluate the ability of dental students at different levels of training to examine known DPRs with different soft-tissue calcification.

Methods

A total of known 100 DPRs with (n=50) and without (n=50) calcification were independently evaluated by four groups: preclinical, first clinical and last clinical dental students, and dentists with less than or equal to 1 year of professional experience in the same time (15 min) and examination conditions. Unity software was used to develop the examination App, which allowed to mark areas with calcifications on the DPRs. The data were statistically analyzed between the groups (significance level: P<0.05) for every location, and the detection rate was calculated as a percentage of detected calcifications.

Results

Results revealed that the overall detection rate of calcifications in all groups was 29.17%. Dentists exhibited the highest detection rate (36.46%), followed by the last- (29.69%), first- (32.29%), and preclinical (15.10%) students.

Conclusion

These findings suggest that clinical experience plays a role in the correct detection of soft-tissue calcifications in DPRs. However, deficiencies in radiological training during dental education may contribute to diagnostic errors. As these can become life-threatening risks, the results highlight the need for early training in the dental curriculum to improve diagnostic performance and minimize possible diagnostic errors.

An Unusually Large Submandibular Sialolith: A Case Report

Sialolithiasis is among the most common pathological conditions of the salivary glands. It is characterized by blockage of the salivary gland excretory duct or by the formation of calcareous concretions, resulting in salivary stasis and causing salivary gland swelling. Most sialoliths generally arise in the submandibular gland and duct. The size of sialoliths ranges from around 1 mm to 10 mm, with some exceeding 15 mm in dimension. Numerous conservative treatments, including milking and palliative therapy, are effective for accessible small stones. Surgical intervention is necessary when the sialoliths are large, inaccessible, or when conservative therapies fail. The present study reports a patient with large multiple submandibular gland sialoliths, with the largest measuring approximately 16 mm by 10 mm. This case highlights the importance of considering sialolithiasis in patients with submandibular swelling and the necessity of surgical intervention for large stones when conservative treatments fail. The patient's symptoms resolved postoperatively, demonstrating the effectiveness of the treatment approach.

Pediatric Salivary Gland Pathology

Benign and malignant salivary gland disorders are uncommon in the pediatric population; however, these can be frequently seen in pediatric otolaryngology or oral and maxillofacial surgery practices. The astute clinician should be aware of the clinical presentation, diagnosis, and management options for common inflammatory, infectious, benign, and malignant disorders of salivary glands.

Management of a Submandibular Sialolith: A Case Report

Sialolithiasis is a condition that is characterized by the obstruction of the salivary gland duct opening by calcified mineral deposits due to various factors discussed in this case report. The most common symptom associated with the pathology is difficulty in deglutition, which can often lead to dehydration due to poor water intake. This, in turn further increases the viscosity of saliva which further promotes the formation of sialoliths. The management is dictated by the location and size of the sialolith, and in this case report, the significance of conservative treatment is emphasized while acknowledging the importance of invasive treatment when necessary.

Microbiomic association between the saliva and salivary stone in patients with sialolithiasis

Salivary stones, known as sialoliths, form within the salivary ducts due to abnormal salivary composition and cause painful symptoms, for which surgical removal is the primary treatment. This study explored the role of the salivary microbial communities in the formation of sialoliths. We conducted a comparative analysis of microbial communities present in the saliva and salivary stones, and sequenced the 16S rRNA gene in samples obtained from patients with sialoliths and from healthy individuals. Although the diversity in the saliva was high, the essential features of the microbial environment in sialoliths were low diversity and evenness. The association of microbial abundance between stones and saliva revealed a positive correlation between Peptostreptococcus and Porphyromonas, and a negative correlation for Pseudomonas in saliva. The functional potential differences between saliva and stones Bacterial chemotaxis and the citrate cycle were negatively correlated with most genera found in salivary stone samples. However, the functions required for organic compound degradation did not differ between the saliva samples. Although some microbes were shared between the sialoliths and saliva, their compositions differed significantly. Our study presents a novel comparison between salivary stones and salivary microbiomes, suggesting potential preventive strategies against sialolithiasis.

What is the impact of previous cholelithiasis on sialolithiasis: A systematic review and meta-analysis

Introduction

A sialolith is a salivary stone usually presenting with swelling and pain in the affected salivary gland, most commonly the submandibular gland. There have been speculations about the association between this condition and other systemic diseases, especially those forming stones, such as nephrolithiasis and cholelithiasis. This systematic review and meta-analysis aimed to summarize the studies assessing the relationship between cholelithiasis and sialolithiasis.

Methods

PubMed/MEDLINE, Scopus, Web of Science, and Embase electronic databases were searched according to the keywords related to both disorders without any publication date or language restriction. Case-control and cohort studies evaluating the relationship between salivary and biliary stones were considered eligible. Quality assessment was performed following Newcastle-Ottawa Scale (NOS) for quality assessment of case-control studies. All meta and statistical analyses were performed with Comprehensive Meta-Analysis software.

Results

Two studies fully complied with the defined eligibility criteria and were included, both of which were case-control studies using national-scale databases. In both surveys, the prevalence of previous gallstones in patients with sialolithiasis was compared to that of a control group. Though one of the studies found that there is no relationship between sialolithiasis and cholelithiasis, the meta-analysis revealed that previous cholelithiasis is significantly more prevalent among patients with sialolithiasis (P = 0.000), with an odds ratio of 2.04.

Conclusion

It seems that cholelithiasis is significantly associated with an increase in salivary stone formation. Therefore, a thorough salivary examination in all patients declaring current or past cholelithiasis is recommended. However, more studies, especially prospective cohorts, are needed to make firmer conclusions.

Sialolithiasis in the Left Submandibular Gland: A Case

The most common illness affecting the salivary glands is submandibular gland sialoliths. The size of the sialolith and the patient's clinical history mainly influence how this salivary system abnormality is treated. This diagnosis is suggested by a history of salivary gland pain or swelling, particularly during mastication. Palliative therapy combined with conservative therapies, such as the milking of the ducts, can effectively treat small and accessible stones. When a stone or stones are large and inaccessible, surgical therapy should be considered if conservative approaches have not proven to be effective. A case of sialolithiasis affecting the left submandibular salivary gland is described in this article. Under local anesthesia, sialolith was removed following the opening of the duct. The wound was closed with sutures, and the patient was advised to practice tongue exercises and to maintain good oral hygiene.

Nanomechanical properties of kidney stones, gallstones and oral stones compared with tap water scale by depth sensing indentation

This article focuses on a description of research performed to identify structural and mechanical properties differences between calculi in stones, such as gallstones, kidney stones, dental tartar, and saliva gland sialolite, were analyzed and compared with tap water stone, in order to set interrelations. In this study, biological hard pebble-like structures were analyzed and compared among them using Scanning Electron Microscopy (SEM), X-Ray diffraction (XRD), and Atomic Force Microscopy (AFM). In addition, Nanoindentation was used to obtain values as example in kidney stones the in; stiffness S = 27,827 ± 620 N/nm elastic modulus E = 27.3 ± 4.5 GPa, hardness H = 1.5 ± 0.5 GPa. Samples with the highest amounts of calcium and magnesium oxides were; Tap water stone (39.60%), followed by dental tartar (39.40%), saliva gland sialolite (29.20%), kidney stones (27.70%), and lastly the gallstones (0.30%). Kidney stones showed in particular, whewellite and kaoulinite crystallographic phases, that confers characteristics of greater crystallization with respect to the other stones. Kidney stones positioned in the major hardness stone in human body with 1.5 GPa. In general, samples with the highest amount of calcium oxides, also showed the highest mechanical properties of H and E. Microstructural characteristics and nano-hardness of tap water stone from drinking water where similar to those of dental tartar and saliva gland sialolite, more research still required to associate health concerns and tap water scale derived from drinking water known as hardwater.

U-shaped fusion convolutional transformer based workflow for fast optical coherence tomography angiography generation in lips

Oral disorders, including oral cancer, pose substantial diagnostic challenges due to late-stage diagnosis, invasive biopsy procedures, and the limitations of existing non-invasive imaging techniques. Optical coherence tomography angiography (OCTA) shows potential in delivering non-invasive, real-time, high-resolution vasculature images. However, the quality of OCTA images are often compromised due to motion artifacts and noise, necessitating more robust and reliable image reconstruction approaches. To address these issues, we propose a novel model, a U-shaped fusion convolutional transformer (UFCT), for the reconstruction of high-quality, low-noise OCTA images from two-repeated OCT scans. UFCT integrates the strengths of convolutional neural networks (CNNs) and transformers, proficiently capturing both local and global image features. According to the qualitative and quantitative analysis in normal and pathological conditions, the performance of the proposed pipeline outperforms that of the traditional OCTA generation methods when only two repeated B-scans are performed. We further provide a comparative study with various CNN and transformer models and conduct ablation studies to validate the effectiveness of our proposed strategies. Based on the results, the UFCT model holds the potential to significantly enhance clinical workflow in oral medicine by facilitating early detection, reducing the need for invasive procedures, and improving overall patient outcomes.

An Aberrant Case of Large Submandibular Gland Sialolith With Obstructive Sialadenitis in a Young Female

Sialolithiasis is a major cause of salivary gland dysfunction. Submandibular sialolithiasis with obstructive sialadenitis is a relatively uncommon condition. Submandibular gland sialolithiasis with obstructive sialadenitis accounts for about 2% of all cases of sialadenitis. We are reporting a case of a 20-year-old female who presented with acute-onset swelling in the right submandibular region. The submandibular gland had a large calculus with pericalcular abscess development, which was clearly visible on pre- and post-contrast computed tomography. Subsequently, surgical excision of the lesion was performed, and calculus was removed.

Sialolithiasis: An Unusually Large Submandibular Salivary Stone

Salivary stones are termed as sialoliths, and the condition is referred to as sialolithiasis. Pain and swelling in the affected area, especially after eating, occur often. Small, easily accessible stones may be managed with conservative methods, such as milking of ducts, along with palliative care, whereas bigger, more difficult-to-reach stones need surgical removal. In this article, we describe a case of sialolithiasis affecting the right submandibular salivary gland, which was treated by removing the gland and stone surgically. When big stones and the gland are removed extra orally, the results are favorable. Submandibular gland sialoliths are the most frequent kind of salivary gland illness. The treatment of this salivary system problem depends on the patient's clinical history, the size of the sialolith, and the degree of cooperation.

Evaluation and management of temporomandibular disorders. Part 2: an orthopaedic physical therapy update on examination and clinical reasoning

Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.

Recovery of gland function after endoscopy-assisted removal of impacted hilo-parenchymal stones in the Wharton's duct

The aim of this study was to evaluate the gland function of patients following endoscopy-assisted removal of impacted hilo-parenchymal stones in the Wharton's duct. The study cohort comprised 115 patients who had undergone successful endoscopy-assisted lithotomy for hilo-parenchymal stones (mean diameter 7.7 mm). Gland function was evaluated at a mean 12 months after surgery using ultrasonography, sialography, and/or sialometry. Postoperative ultrasonography of 51 affected glands revealed a regular gland size in 58.8%, normal parenchyma density in 51.0%, and ductal ectasia in 80.4%. Postoperative sialograms of 109 affected glands were scored as type I (approximately normal) in 13 cases, type II (saccular ectasia of the hilo-parenchymal duct with/without stenosis, and no contrast retention) in 64, type III (saccular ectasia of the hilo-parenchymal duct with/without stenosis, and mild contrast retention) in 23, and type IV (poor shape of the main duct with evident contrast retention) in nine cases. The existence of ductal ectasia corresponded well to larger stone cases (P = 0.002). In the postoperative sialometry of 35 patients with unilateral stones, differences between the two sides were insignificant (P > 0.05). For patients with hilo-parenchymal submandibular gland stones, endoscopy-assisted surgery and extended postoperative follow-up help preserve the gland with good function.

Proteomic analysis of sialoliths from calcified, lipid and mixed groups as a source of potential biomarkers of deposit formation in the salivary glands

Salivary stones, also known as sialoliths, are formed in a pathological situation in the salivary glands. So far, neither the mechanism of their formation nor the factors predisposing to their formation are known despite several hypotheses. While they do not directly threaten human life, they significantly deteriorate the patient's quality of life. Although this is not a typical research material, attempts are made to apply various analytical tools to characterise sialoliths and search for the biomarkers in their proteomes. In this work, we used mass spectrometry and SWATH-MS qualitative and quantitative analysis to investigate the composition and select proteins that may contribute to solid deposits in the salivary glands. Twenty sialoliths, previously characterized spectroscopically and divided into the following groups: calcified (CAL), lipid (LIP) and mixed (MIX), were used for the study. Proteins unique for each of the groups were found, including: for the CAL group among them, e.g. proteins from the S100 group (S100 A8/A12 and P), mucin 7 (MUC7), keratins (KRT1/2/4/5/13), elastase (ELANE) or stomatin (STOM); proteins for the LIP group-transthyretin (TTR), lactotransferrin (LTF), matrix Gla protein (MPG), submandibular gland androgen-regulated protein 3 (SMR3A); mixed stones had the fewest unique proteins. Bacterial proteins present in sialoliths have also been identified. The analysis of the results indicates the possible role of bacterial infections, disturbances in calcium metabolism and neutrophil extracellular traps (NETs) in the formation of sialoliths.

Treatment outcomes of sialendoscopy for submandibular gland sialolithiasis

OBJECTIVE

Sialendoscopy is a procedure used to remove salivary stones intraorally using a sialendoscope. In this study, we identified treatment outcomes of sialendoscopic surgery and identified predictive factors for successful stone removal by sialendoscopy alone.

METHODS

We assembled the medical records of 144 patients who underwent sialendoscopic surgery for submandibular gland sialolithiasis at the Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical University, from October 2010 to November 2021, and collected patient backgrounds, medical condition, perioperative factors including operation method and complications, postoperative course, and stone constituents from a clinical laboratory testing company.

RESULTS

Submandibular gland stones were successfully removed using sialendoscopy in 58 patients (40%). In multivariate analysis, location, major axis, and mobility of the stones were independent factors for successful removal. In receiver operating characteristic analysis, <7.5 mm of a major axis may be used as a measuring standard for successful removal. Removal of parenchymal stones is prone to involve prolonged operation times, increased postoperative complications, and development of retained stones. The stones mainly consisted of calcium phosphate and protein, with content percentages ranging from 0 to 98% (median 37%) and from 0 to 100% (median 63%), respectively. The percentage of calcium phosphate was negatively correlated with the number of floating stones and successful stone removal.

CONCLUSION

Sialendoscopy is an aesthetically attractive treatment for sialolithiasis that avoids cervical incisions. The present results showed not only known but also new predictive factors for the successful removal of stones (<7.5 mm) and percentage of calcium phosphate. Moreover, our results suggest that careful consideration is required regarding the indication of sialendoscopic surgery in patients with parenchymal stones.

Sialolithiasis: mineralogical composition, crystalline structure, calculus site, and epidemiological features

The purpose of this paper was to describe the characteristics of salivary calculi and their relationship to epidemiological factors, through a cross-sectional study. We analysed 100 calculi obtained in 2017-2021. Patient data including age, time since onset of symptoms, gland involved, and site of location in the salivary system were studied. The calculi were studied to determine their morphological features using scanning electron microscopy and energy dispersive plain radiographic analysis. Most of the calculi had formed in the submandibular gland (SG) (82%). The mean age of patients at onset was 45.83 years; patients presenting parotid gland (PG) stones were somewhat older (p = 0.031). The mean time since the onset of symptoms was longer in PG calculi (p = 0.038). The most common lithiasis site was the main duct (74%), followed by the hilum (22%). Hilar stones were the largest (p < 0.05) and heaviest (p = 0.028). Octacalcium phosphate (OCP) was the most common crystalline phase (Cp) founded, followed by hydroxyapatite (HA) and whitlockite (WH). Specifically, OCP had a higher presence in PG calculi (p = 0.029) and WH was the most common phase in SG calculi (p = 0.017). The most prevalent site of lithiasis was the main duct, and the largest and heaviest calculi were found in the SG. PG stones were associated with a longer history of symptoms and older age. OCP was the most frequent Cp of the calculi studied, and the main Cp in PG stones. WH was the predominant Cp in SG stones. The Cp of the calculi was not influenced by location, patient age, or time of symptoms.

Lactoferrin and the development of salivary stones: a pilot study

Salivary stones (sialoliths) are calcified structures located in the ductal system of the major salivary glands. Their exact cause is not clear but in general they are characterized by concentric inorganic (hydroxyapatite) layers. The formation is a slow intermittent process which may result in enlargement of the sialolith causing obstruction of saliva secretion resulting in mealtime related pain and swelling of the affected salivary gland. Various studies reported the presence of organic material such as proteins and lipids in the core of sialoliths. In the present study the protein composition of twenty submandibular sialoliths was analyzed. It was found that proteins contributed on average 5% to the dry weight of submandibular stones whereby small salivary stones contained more extractable proteins than large salivary stones. Using a combination of SDS-PAGE gel electrophoresis and Western blotting, we identified α-amylase (in all stones; 100%), lysozyme (95%), lactoferrin (85%), secretory-IgA (75%), MUC7 (60%), complement C4 (60%) and C-reactive protein (35%). The presence, and the combinations, of lactoferrin, lysozyme, s-IgA and α-amylase in sialoliths was confirmed by ELISA. The gradually increasing size of a sialolith might provoke a local inflammatory response in the duct of the submandibular gland whereby the relatively low concentrations of lactoferrin and lysozyme may originate from neutrophils. The interaction of lactoferrin with s-IgA could contribute to the accumulation of lactoferrin in sialoliths. In summary, these results suggest a new pathophysiological role for lactoferrin, in the formation of sialoliths.

Lactoferrin and the development of salivary stones: a pilot study

Salivary stones (sialoliths) are calcified structures located in the ductal system of the major salivary glands. Their exact cause is not clear but in general they are characterized by concentric inorganic (hydroxyapatite) layers. The formation is a slow intermittent process which may result in enlargement of the sialolith causing obstruction of saliva secretion resulting in mealtime related pain and swelling of the affected salivary gland. Various studies reported the presence of organic material such as proteins and lipids in the core of sialoliths. In the present study the protein composition of twenty submandibular sialoliths was analyzed. It was found that proteins contributed on average 5% to the dry weight of submandibular stones whereby small salivary stones contained more extractable proteins than large salivary stones. Using a combination of SDS-PAGE gel electrophoresis and Western blotting, we identified α-amylase (in all stones; 100%), lysozyme (95%), lactoferrin (85%), secretory-IgA (75%), MUC7 (60%), complement C4 (60%) and C-reactive protein (35%). The presence, and the combinations, of lactoferrin, lysozyme, s-IgA and α-amylase in sialoliths was confirmed by ELISA. The gradually increasing size of a sialolith might provoke a local inflammatory response in the duct of the submandibular gland whereby the relatively low concentrations of lactoferrin and lysozyme may originate from neutrophils. The interaction of lactoferrin with s-IgA could contribute to the accumulation of lactoferrin in sialoliths. In summary, these results suggest a new pathophysiological role for lactoferrin, in the formation of sialoliths.

Impaired spontaneous secretion as a potential factor in the development of sialolithiasis in the submandibular gland: A preliminary sialoscintigraphic study

Objectives

The development of sialolithiasis is commonly related to local factors, such as the retrograde migration of foods, bacteria, or foreign bodies from the oral cavity. The association of sialolithiasis and saliva stasis resulting from decreased spontaneous secretion remains largely unexplored. The current study investigated the potential role of impaired spontaneous secretion in association with the formation of submandibular gland calculi.

Study Design

A retrospective cohort study.

Methods

Between September 2016 and December 2017, 11 patients with unilateral submandibular gland sialolithiasis confirmed with sialendoscopy were assigned to the experimental group. Another 35 patients clinically diagnosed with parotid obstructive sialadenitis were assigned as the control group. The slope changes of the isotope count curve of the unaffected submandibular gland in the experimental group and the bilateral submandibular glands in the control group were calculated and compared to estimate the spontaneous secretion differences. The degree of spontaneous secretion was defined as the slope changes in the steady ascending stage of the scintigraphic exam.

Results

The slope decline (degree of spontaneous secretion) on the unaffected side in patients with single-gland submandibular obstructive sialadenitis was significantly lower than that in the control individuals (p = .002). In contrast, the between-group comparison in the unaffected parotid glands revealed no difference in the slope decline.

Conclusion

The spontaneous secretion of the submandibular gland in patients with submandibular sialolithiasis was decreased compared to that in patients without submandibular sialolithiasis. This phenomenon might be associated with the development of sialolithiasis.

Level of Evidence

3.

The changing landscape of pediatric salivary gland stones: A half-century systematic review

OBJECTIVE

To assess the evidence for pediatric sialolithiasis, including its demographic characteristics, diagnosis, and demonstrate the shift in its treatment paradigm.

DESIGN

A systematic review of sources from the Medline and Embase databases was conducted from inception to Dec 4, 2020. Two researchers independently extracted data and assessed quality.

PATIENTS

Patients under the age of 18 with sialolithiasis were included.

MAIN OUTCOME MEASURES

Study design, cohort size, age, sex, symptoms, stone characteristics, diagnostic modality and intervention were collected data points.

RESULTS

Forty-one studies with 243 patients were included in the review, of which 40 were case reports or series. Most stones were found in the submandibular gland (n = 210, 85.4%) and were single stones (n = 101, 71.1%). Average stone size was 7.7 mm. The most common diagnostic imaging modality used was ultrasound (n = 73, 47.4%), shifting from plain radiograph which was favoured in earlier years. Similarly, open gland excision was historically preferred, but since 2000, sialoendoscopy comprised 40.5% of all treatment modalities and continues to increase in prevalence, up to 52.1% by 2020. Extracorporeal shock wave lithotripsy was associated with the highest complication rate of 54.2%.

CONCLUSIONS

The pediatric sialolithiasis diagnostic and therapeutic landscape has changed with ultrasound replacing plain radiographs, and sialoendoscopy replacing submandibular gland excision. Further high-level quality evidence research is required to refine the indications, effectiveness, and safety of sialoendoscopy in pediatric sialolithiasis.

Multiple Faces of Cervical Lesions in Children

Pediatric sialolithiasis is a rare condition causing tumefaction, induration, redness, and pain of the affected gland. When the submandibular gland is involved, the lesion can be mistaken for an adenopathy. As there are few studies to elucidate this condition in children, we present a rare case of a 16-year-old female with suggestive symptoms, in which initial clinical examination and two ultrasound examinations mistook the lesion for an adenopathy. A computed tomography examination was performed and the correct diagnosis was established. The patient was sent for oro-maxilo-facial examination and sialolithotomy was performed. A 10-mm yellow calculus was extracted and postoperative case evolution was favorable under wide spectrum antibiotherapy, oral nonsteroidal anti-inflammatory therapy and silagog alimentation. Although submandibular adenopathies are much more frequent in the pediatric age group, when faced with a firm, immobile submandibular lesion, the pediatrician should consider the sialolithiasis diagnosis.

Rapid development of a salivary calculus in submandibular gland and its potential causes in a young victim following Russell's viper bite

Russell's viper bites are known to cause a range of haemotoxic, neurotoxic, myotoxic, cytotoxic and nephrotoxic complications. However, the impact of Russell's viper bites as well as bites from other venomous snakes on sialolithiasis has not been previously reported. Here, we present an interesting case where a Russell's viper bite induced the rapid development of a calculus in submandibular gland in a 10-year-old boy. Upon admission, the victim did not show any symptoms of swelling and/or pain around his oral cavity. He received antivenom treatment to normalise his coagulation parameters, however, on day three he developed swelling and extreme pain around his right mandibular region. An ultrasound investigation revealed the presence of a calculus in his submandibular gland, which was removed using a minor surgical procedure. The histopathological examination revealed this as a poorly calcified salivary calculus, which is composed of cell debris, mucopolysaccharides and lipids. The mechanisms behind its rapid development following a snakebite are unclear although this could be linked to excessive inflammation or modifications to the composition of saliva induced by venom toxins or other unknown factors. This report reveals an unusual complication induced by a Russell's viper bite and alerts clinicians who treat snakebites to be aware of such envenomation effects. Moreover, this will lead to novel research to explore the relationship between venom toxins and functions of salivary glands.

Utility of Ultrasonography for Diagnosis of Salivary Gland Sialolithiasis: A Meta-Analysis

OBJECTIVES

We hypothesized that ultrasonography for salivary gland stone detection would have a diagnostic accuracy similar to that confirmed by sialendoscopy, sialography, or surgery. Therefore, we evaluated the diagnostic characteristics of ultrasonography in terms of submandibular and parotid stone detection compared to confirmatory methods.

METHODS

We searched PubMed, Embase, the Web of Science, SCOPUS, and the Cochrane database to October 31, 2021. The risk of bias was evaluated using the QADAS-2 tool.

RESULTS

Ten studies involving 1393 patients were included in the analysis. The diagnostic odds ratio of ultrasonography was 162.6013 (95% confidence interval [CI] [53.9883; 489.7208] and I² value 81.0%). The area under the summary receiver operating characteristic curve was 0.963. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.8992 (95% CI [0.8534; 0.9318]; I²  = 79.9%), 0.9664 (95% CI [0.9290; 0.9844], I²  = 65.6%), 0.8076 (95% CI [0.7256; 0.8694]; I²  = 80.4%), and 0.9853 (95% CI [0.9629; 0.9943]; I²  = 77.4%), respectively. However, high-level among-study heterogeneity (I²  ≥ 50%) was evident, attributable to the inclusion of different glands. On subgroup analysis, significant differences in the negative predictive values (parotid gland only [0.9392], submandibular gland only [0.6718], and parotid and submandibular glands [0.8105]) were apparent. We found no significant among-study difference in the sensitivity, specificity, positive predictive value, or diagnostic odds ratio (P > .05).

CONCLUSION

Ultrasonography usefully detects submandibular and parotid gland stones. Ultrasonography of the parotid gland was associated with the highest diagnostic accuracy, but further clinical studies are needed.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

The Translational Role of MUC8 in Salivary Glands: A Potential Biomarker for Salivary Stone Disease?

Mucin (MUC) 8 has been shown to play an important role in respiratory disease and inflammatory responses. In the present study, we investigated the question of whether MUC8 is also produced and secreted by salivary glands and whether it may also play a role in the oral cavity in the context of inflammatory processes or in the context of salivary stone formation. Tissue samples from parotid and submandibular glands of body donors (n = 6, age range 63–88 years), as well as surgically removed salivary stones from patients (n = 38, age range 48–72 years) with parotid and submandibular stone disease were immunohistochemically analyzed targeting MUC8 and TNFα. The presence of MUC8 in salivary stones was additionally analyzed by dot blot analyses. Moreover, saliva samples from patients (n = 10, age range 51–72 years), who had a salivary stone of the submandibular gland on one side were compared with saliva samples from the other “healthy” side, which did not have a salivary stone, by ELISA. Positive MUC8 was detectable in the inter- and intralobular excretory ducts of both glands (parotid and submandibular). The glandular acini showed no reactivity. TNFα revealed comparable reactivity to MUC8 in the glandular excretory ducts and also did not react in glandular acini. Salivary stones demonstrated a characteristic distribution pattern of MUC8 that differed between parotid and submandibular salivary stones. The mean MUC8 concentration was 71.06 ng/mL in female and 33.21 ng/mL in male subjects (p = 0.156). Saliva from the side with salivary calculi contained significantly (15-fold) higher MUC8 concentration levels than saliva from the healthy side (p = 0.0005). MUC8 concentration in salivary stones varied from 4.59 ng/mL to 202.83 ng/mL. In females, the MUC8 concentration in salivary stones was significantly (2.3-fold) higher, with an average of 82.84 ng/mL compared to 25.27 ng/mL in male patients (p = 0.034). MUC8 is secreted in the excretory duct system of salivary glands and released into saliva. Importantly, MUC8 salivary concentrations vary greatly between individuals. In addition, the MUC8 concentration is gender-dependent (♀ > ♂). In the context of salivary stone diseases, MUC8 is highly secreted in saliva. The findings support a role for MUC8 in the context of inflammatory events and salivary stone formation. The findings allow conclusions on a gender-dependent component of MUC8.

Trial Proteomic Qualitative and Quantitative Analysis of the Protein Matrix of Submandibular Sialoliths

Our studies aimed to explore the protein components of the matrix of human submandibular gland sialoliths. A qualitative analysis was carried out based on the filter aided sample preparation (FASP) methodology. In the protein extraction process, we evaluated the applicability of the standard demineralization step and the use of a lysis buffer containing sodium dodecyl sulfate (SDS) and dithiothreitol (DTT). The analysis of fragmentation spectra based on the human database allowed for the identification of 254 human proteins present in the deposits. In addition, the use of multi-round search in the PEAKS Studio program against the bacterial base allowed for the identification of 393 proteins of bacterial origin present in the extract obtained from sialolith, which so far has not been carried out for this biological material. Furthermore, we successfully applied the SWATH methodology, allowing for a relative quantitative analysis of human proteins present in deposits. The obtained results correlate with the classification of sialoliths proposed by Tretiakow. The performed functional analysis allowed for the first time the selection of proteins, the levels of which differ between the tested samples, which may suggest the role of these proteins in the calcification process in different types of sialoliths. These are preliminary studies, and drawing specific conclusions requires research on a larger group, but it provides us the basis for the continuation of the work that has already begun.

Painless Giant Submandibular Gland Sialolith: A Case Report

Sialolithiasis is one of the most common diseases involving the salivary glands. It is a condition that occurs due to an obstruction in a salivary gland or its duct due to a calculus. The formation of a salivary stone is believed to be secondary to the deposition of mineral salts around a nidus, which is frequently associated with a recurrent bacterial infection. Patients with submandibular sialolithiasis usually present with acute swelling over the neck associated with pain, fever, and purulent intraoral discharge. The size of the calculus varies from <1 mm to a few centimeters. The frequency of sialolithiasis is relatively common. It is estimated to affect 12 in 1000 of the adult population. However, the occurrence of giant sialoliths, >15 mm in any diameter, is rare. Here, we describe our experience with a case of giant submandibular sialolithiasis measuring 25 mm presenting as a painless submandibular mass. The patient underwent submandibular gland excision followed by a full recovery.

Relationship between volume of submandibular salivary stones in vivo determined with Cone-Beam Computer Tomography and in vitro with micro-Computer Tomography

Background

Successful removal of salivary stones depends on exact pretreatment information of the location, the size and shape of the stones. This study aimed to compare the volume of submandibular sialoliths determined by preoperative Cone-Beam Computer Tomography (CBCT) scans with the volume of the removed stones on micro-Computer Tomography (micro-CT) scans.

Material and Methods

In this study, using twenty-one submandibular sialoliths, the pretreatment volumes in-vivo measured on CBCT were compared to the volumes of removed stones determined by micro-CT scans. The volume measured on micro-CT scans served as the gold standard. Pre-operative CBCT’s and in-vitro micro-CT’s were converted into standard tessellation language models (STL-models) using an image segmentation software package. The CBCT and micro-CT images of the stones were subsequently metrologically assessed and compared to each other using reverse engineering software.

Results

Volumes of submandibular sialoliths determined by CBCT’s correlated significantly with volumes measured on micro-CT’s (Spearman’s coefficient r = 0.916). The interquartile range (IQR) for the volume measured with micro-CT was 117.23. The median is 26.41. For the volume measured with CBCT the IQR was 141.3 and the median 36.61. The average volume on micro-CT is smaller than on CBCT.

Conclusions

When using CBCT-scans for the detection of submandibular sialoliths one should realize that in-vivo those stones are actually a fraction smaller than assessed on the preoperative scan. This is important when cut-off values of sizes of stones are used in the pretreatment planning of stone removal.

Key words:Salivary stone, sialolith, CBCT, micro-CT, volume.

Ectopic mineralisation of the mandibular symphysis in ENT1 knockout mice: A model of dystrophic calcification

Equilibrative nucleoside transporter 1 (ENT1) transfers nucleosides, such as adenosine, across plasma membranes. We reported previously that mice lacking ENT1 (ENT1 ^-/- ) exhibit progressive ectopic calcification of spinal tissues-a phenotype resembling diffuse idiopathic skeletal hyperostosis (DISH) in humans. Our objective was to investigate potential calcification of orofacial tissues in ENT1 ^-/- mice. Heads of wild-type mice and ENT1 ^-/- mice from 3 to 17 months were evaluated using microcomputed tomography (μCT). Some heads were decalcified and processed for histological assessment. Other heads were examined using energy dispersive X-ray spectroscopy and micro X-ray diffraction. Using μCT, ENT1 ^-/- mice showed extensive radiopaque lesions within the mandibular symphysis, the severity of which increased with advancing age. Histologically, at 6 months these ectopic radiopacities were found to correspond to acellular, amorphous, eosinophilic material, with no evidence of inflammatory cells. Because lesions were localised to the symphysis, we identified early pathological changes at 3 months and observed that lesions initiated specifically within the fibrocartilage pad. Energy-dispersive X-ray spectroscopy of ectopic lesions revealed large amounts of calcium and phosphorous in a molar ratio of ~1.59, and X-ray diffraction profiles matched that of calcium-deficient hydroxyapatite. This is the first characterisation of ectopic calcifications within the mandibular symphysis of ENT1 ^-/- mice, indicating a role for ENT1 and adenosine metabolism in regulating calcification of fibrocartilaginous tissues. Moreover, these murine lesions resemble areas of dystrophic calcification in the spinal tissues of humans with DISH. Importantly, ectopic calcifications develop in a reproducible temporal pattern within a well-defined anatomical region and, thus, provide a model for determining the cellular and molecular pathways underlying ectopic calcification in DISH and related disorders.

Concurrent giant sialoliths within the submandibular gland parenchyma and distal segment of Wharton's duct: Novel case report

OBJECTIVE

This article discusses the clinical significance of an unusual case of the simultaneous occurrence of 2 giant sialoliths within the ipsilateral submandibular gland and distal aspect of Wharton's duct in a 63-year-old patient.

BACKGROUND

The majority of submandibular gland sialoliths are found in Wharton's duct, with fewer within the gland parenchyma. Giant sialoliths (exceeding 15 mm in size) are rare.

MATERIALS AND METHODS

An asymptomatic, otherwise healthy older patient sought dental care and underwent a comprehensive oral and radiographic examination.

RESULTS

A panoramic radiograph revealed 2 incidental radiopaque structures, representing giant sialoliths within the submandibular gland and along the distal segment of Wharton's duct. This synchronous finding apparently represents the first case reported in the geriatric literature.

CONCLUSIONS

The detection of 1 salivary stone should heighten the scrutiny for additional stones. Practitioners should carefully weigh the risk of sialolith removal versus deferment of treatment in older medically compromised patients.

Classification of submandibular salivary stones based on ultrastructural studies

INTRODUCTION

Sialolithiasis remains a clinical problem with unclear etiopathogenesis, lack of prevention methods, and only surgical treatment.

MATERIALS AND METHODS

An ultrastructure examination of submandibular sialoliths obtained from patients with chronic sialolithiasis was conducted using a scanning electron microscope and X-ray photoelectron spectroscopy.

RESULTS

Based on the results, we divided sialoliths into three types: calcified (CAL), organic/lipid (LIP), and mixed (MIX). The core structure of the CAL and MIX is very similar. The core of the LIP has a prevalence of organic components. The intermediate layers' structure of the CAL is different from LIP and MIX. In LIP and MIX, the organic component begins to increase in intermediate layers rapidly. The structure of the superficial layers for all types of sialoliths is similar.

CONCLUSIONS

We introduced a new classification of the submandibular salivary gland stones. Based on the results, it can be said that sialoliths type CAL and LIP have their separate path of origin and development, while MIX is formed as CAL stone, and the further pathway of their growth passes as LIP stones. Organic components were much more than inorganic in all layers of salivary gland stones, which highly prevents their dissolution in the patient's salivary gland duct.

Neutrophil Extracellular Traps Promote the Development and Growth of Human Salivary Stones

Salivary gland stones, or sialoliths, are the most common cause of the obstruction of salivary glands. The mechanism behind the formation of sialoliths has been elusive. Symptomatic sialolithiasis has a prevalence of 0.45% in the general population, is characterized by recurrent painful periprandial swelling of the affected gland, and often results in sialadenitis with the need for surgical intervention. Here, we show by the use of immunohistochemistry, immunofluorescence, computed tomography (CT) scans and reconstructions, special dye techniques, bacterial genotyping, and enzyme activity analyses that neutrophil extracellular traps (NETs) initiate the formation and growth of sialoliths in humans. The deposition of neutrophil granulocyte extracellular DNA around small crystals results in the dense aggregation of the latter, and the subsequent mineralization creates alternating layers of dense mineral, which are predominantly calcium salt deposits and DNA. The further agglomeration and appositional growth of these structures promotes the development of macroscopic sialoliths that finally occlude the efferent ducts of the salivary glands, causing clinical symptoms and salivary gland dysfunction. These findings provide an entirely novel insight into the mechanism of sialolithogenesis, in which an immune system-mediated response essentially participates in the physicochemical process of concrement formation and growth.

Sialo-cutaneous fistula with ectopic submandibular gland sialolith, revealing a hidden ipsilateral enlarged and elongated styloid process: a consideration based on CT findings

Sialolithiasis is a common salivary pathology, and an uncommon complication of sialadenitis and sialolithiasis is the formation of fistulous tracts to other compartments. Submandibular gland sialo-oral fistulae are not particularly remarkable, given the location of the gland and Wharton's duct, but submandibular sialolith-associated fistulae to other cervico-facial compartments (transcervical sialo-cutaneous and sialo-pharyngeal fistulae) are much less common. We report herein an unusual case of a 49-year-old obese man with sialo-cutaneous fistula containing a large, ectopic sialolith in subcutaneous tissue that was expected to undergo spontaneous elimination, but revealed hidden Eagle syndrome featuring an ipsilateral enlarged, elongated styloid process. Furthermore, we offer a thorough review of the literature regarding sialo-fistulae and highlight the relationship between an abnormal styloid process and submandibular sialadenitis with sialolithiasis and new tract formation based on computed tomography.

Sialolithiasis-Do Early Diagnosis and Removal Minimize Post-Operative Morbidity?

Background and objectives: Sialolithiasis is an inflammation of a salivary gland due to obstruction of salivary flow by a sialolith. We aim to assess potential factors that may predict lower morbidity following endoscopically assisted per-oral sialolith removal. Materials and Methods: Retrospective cohort study. Retrospective review of 100 records of patients with sialolithiasis, following surgical sialolith removal. A single medical center (Department of oral and maxillofacial surgery-Rabin Medical Center, Beilinson & Hasharon-Israel) survey. Data were gleaned from the patient files based on a structured questionnaire. Factors that may predict morbidity were evaluated using linear regression equation. Results: 59 of the subjects were men and 41 were women. The mean age of the patients in the study was 50 ± 17.5 years. Sialolith volume and past antibiotic treatment were positively associated while age was negatively associated with hospitalization duration. Conclusion: Early sialolith diagnosis and removal may lower postoperative morbidity.

A comprehensive analysis of sialolith proteins and the clinical implications

BACKGROUND

Sialolithiasis or salivary gland stones are associated with high clinical morbidity. The advances in the treatment of sialolithiasis has been limited, however, by our understanding of their composition. More specifically, there is little information regarding the formation and composition of the protein matrix, the role of mineralogical deposition, or the contributions of cell epithelium and secretions from the salivary glands. A better understanding of these stone characteristics could pave the way for future non-invasive treatment strategies.

METHODS

Twenty-nine high-quality ductal stone samples were analyzed. The preparation included successive washings to avoid contamination from saliva and blood. The sialoliths were macerated in liquid nitrogen and the maceration was subjected to a sequential, four-step, protein extraction. The four fractions were pooled together, and a standardized aliquot was subjected to tandem liquid chromatography mass spectrometry (LCMS). The data output was subjected to a basic descriptive statistical analysis for parametric confirmation and a subsequent G.O.-KEGG data base functional analysis and classification for biological interpretation.

RESULTS

The LC-MS output detected 6934 proteins, 824 of which were unique for individual stones. An example of our sialolith protein data is available via ProteomeXchange with the identifier PXD012422. More important, the sialoliths averaged 53% homology with bone-forming proteins that served as a standard comparison, which favorably compared with 62% homology identified among all sialolith sample proteins. The non-homologous protein fraction had a highly variable protein identity. The G.O.-KEGG functional analysis indicated that extracellular exosomes are a primary cellular component in sialolithiasis. Light and electron microscopy also confirmed the presence of exosomal-like features and the presence of intracellular microcrystals.

CONCLUSION

Sialolith formation presents similarities with the hyperoxaluria that forms kidney stones, which suggests the possibility of a common origin. Further verification of a common origin could fundamentally change the way in which lithiasis is studied and treated.

Ultrastructural analysis of the submandibular sialoliths: Raman spectroscopy and electron back-scatter studies

The aim of work was the epidemiological analysis of the occurrence of sialolithiasis of the submandibular gland in adults and the evaluation of the ultrastructure of salivary stones. The study sample consisted of 44 sialoliths. Analysis of the structure and chemical composition of sialoliths was performed using a Scanning Electron Microscope and Raman Spectroscopy. Comparing our results with the literature we can say that the epidemiology of sialolithiasis has not changed significantly over the past 50 years. A wide variety of sialoliths structure was observed. In 75% (33) cases a layered structure of salivary stones was observed, while in 25% (11) - homogeneous structure. The various distribution of organic and inorganic components was observed among all the analyzed sialoliths. Raman spectroscopy allows for preliminary analysis of the sialoliths structure with only a qualitative assessment of their composition, which significantly reduces the research value of this method. The presence of organic and inorganic compounds in the core and inner layers of the salivary glands stones confirms 2 basic theories of the formation of sialoliths: inflammation and deposition of the inorganic component as a result of disruption of saliva flow in the salivary glands.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

Salivary Gland Diseases

A variety of diseases ranging from obstructions, infections, to benign and malignant tumors occur in salivary glands. The most common problem is painful blockage of ducts by stones that prevents drainage of saliva. Sialadenitis can be due to either infectious or noninfectious factors. Bacterial or viral infections are the most common causes of acute sialadenitis. Staphylococcus is the usual bacterial cause, whereas paramyxovirus (mumps) is the common viral cause. Eighty percent of salivary tumors are benign, whereas about 20% are malignant. Most tumors occur in the parotid gland and on the hard palate. Classifications, imaging, and suggested treatment are described.

Dual-Source Dual-Energy CT in Submandibular Sialolithiasis: Reliability and Radiation Burden

OBJECTIVE. This study aims to compare the diagnostic accuracy of virtual unenhanced CT images derived from dual-source dual-energy contrast-enhanced CT with that of standard unenhanced CT images for evaluation of sialolithiasis. MATERIALS AND METHODS. All dual-energy CT studies of the neck performed during the preceding 5 years were reviewed for submandibular gland calculi. Only patients who had unenhanced CT and contrast-enhanced CT performed as part of the same evaluation were included in this study. This review yielded 30 patients. Virtual unenhanced CT images were derived from the dual-energy dataset and compared with the true unenhanced CT images by two separate radiologists who assessed the total number of calculi encountered, their location, the largest dimension, and the attenuation of the calculi. The radiation burden incurred for true unenhanced CT and virtual unenhanced CT and the total radiation burden were calculated. RESULTS. Our analysis revealed that measurements of stone size showed good interobserver agreement. The mean stone size was 7.9 ± 5.9 (SD) mm on virtual unenhanced CT and 8.4 ± 5.9 mm on true unenhanced CT (range, 2.0-31.8 mm); the difference was statistically insignificant. The mean stone attenuation differed considerably (p < 0.01) between the virtual and true unenhanced CT images (494.8 ± 187.5 HU and 924.4 ± 374.9 HU, respectively), but correlated well. The mean radiation dose for a dual-phase IV contrast-enhanced CT study was 23.13 mGy (volume CT dose index). The mean dose was 10.93 mGy for the true unenhanced CT phase, thereby suggesting a 47.25% reduction in administered radiation dose when a single-phase contrast-enhanced CT study with virtual unenhanced image reconstructions is performed. CONCLUSION. Virtual unenhanced CT images derived from dual-source dual-energy CT scans of the neck provide accurate assessment of sialolithiasis akin to that provided by conventional CT protocols but at only a fraction of the radiation dosage.