By Erik Paulson, D.O.By Erik Paulson, D.O.

HistoryHistory

• CC- 15 y.o. male c/o pain and swelling in CC- 15 y.o. male c/o pain and swelling in jaw.jaw.

• Began yesterday, thought it might be Began yesterday, thought it might be strep throat or something so he began strep throat or something so he began taking left over Amoxicillin from last year.taking left over Amoxicillin from last year.

• NKDANKDA• Seasonal allergies relieved by Claritin and Seasonal allergies relieved by Claritin and

Benadryl.Benadryl.• No other medsNo other meds• Vaccinations up to dateVaccinations up to date

Physical examPhysical exam

• Vitals- 101.2, 95, 16, 122/80Vitals- 101.2, 95, 16, 122/80

• Swollen, tender and slightly Swollen, tender and slightly erythematous area on left side of erythematous area on left side of neck just inferior to mandible.neck just inferior to mandible.

• Decreased in size after pressure was Decreased in size after pressure was applied.applied.

Differential DiagnosisDifferential Diagnosis

• InfectionInfection– LymphadenitisLymphadenitis

• MonoMono• StrepStrep

– SialadenitisSialadenitis• Mumps- vaccinations are up to dateMumps- vaccinations are up to date• StoneStone• Sjogren’sSjogren’s

– AbscessAbscess

• NeoplasticNeoplastic

LabsLabs

• CBC- Increased white count w/ left CBC- Increased white count w/ left shiftshift

• Rapid strep –Rapid strep –

• Mono spot –Mono spot –

• All other labs normalAll other labs normal

http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow96.jpg

DiagnosisDiagnosis

• Sialolithiasis with secondary Sialolithiasis with secondary sialadenitissialadenitis

Quiz timeQuiz time

• Duct from Parotid gland is called?Duct from Parotid gland is called?– Stensen’s ductStensen’s duct

• Duct from Submandibular gland is Duct from Submandibular gland is called?called?– Wharton’s ductWharton’s duct

Pathophysiology Pathophysiology

• DehydrationDehydration– Concentration of saliva Concentration of saliva

• Fasting or AnorexiaFasting or Anorexia– Stasis of saliva Stasis of saliva

• Drugs- Anti-histamines, Anti-cholinergics.Drugs- Anti-histamines, Anti-cholinergics.– Decrease production of salivaDecrease production of saliva

• Stone can cause stasis of saliva and Stone can cause stasis of saliva and subsequent bacterial ascent into the gland.subsequent bacterial ascent into the gland.– Infection most commonly from S. aureus or Infection most commonly from S. aureus or

Strep Viridans.Strep Viridans.

Fun Facts about Fun Facts about SialolithiasisSialolithiasis

• Twice as common in malesTwice as common in males

• 1% incidence at autopsy1% incidence at autopsy

• Stones are usually made of calcium Stones are usually made of calcium phosphatephosphate

TreatmentTreatment

• ConservativeConservative– Warm compressesWarm compresses– Sour candySour candy– Pain relief- Ibuprofen 800mg. PO Q8hrs PRN pain.Pain relief- Ibuprofen 800mg. PO Q8hrs PRN pain.– Oral fluidsOral fluids– Discontinue anti-histaminesDiscontinue anti-histamines– Oral antibiotics- Cefalexin 500mg PO QID X 7d.Oral antibiotics- Cefalexin 500mg PO QID X 7d.

• SurgicalSurgical– Wire basket retrieval under fluoroscopy.Wire basket retrieval under fluoroscopy.– Duct cannulationDuct cannulation– Gland removal for recurrent casesGland removal for recurrent cases

• LithotripsyLithotripsy

Osteopathic treatmentOsteopathic treatment

• Gentle massage of the salivary gland may Gentle massage of the salivary gland may free calculi that are near the end of the free calculi that are near the end of the duct. It may also decrease the amount of duct. It may also decrease the amount of saliva retained in the gland and provide saliva retained in the gland and provide symptomatic improvement.symptomatic improvement.

• Lymphatic pumps to improve immune Lymphatic pumps to improve immune function.function.

• Increase/ normalize parasympathetic tone, Increase/ normalize parasympathetic tone, decrease/ normalize sympathetic tone.decrease/ normalize sympathetic tone.

OutcomeOutcome

• Unknown, but he did not return to Unknown, but he did not return to the ED within the next two weeks.the ED within the next two weeks.

ReferencesReferences

• http://0-www.utdol.com.library.touro.edu/http://0-www.utdol.com.library.touro.edu/online/content/topic.do?online/content/topic.do?topicKey=prim_ent/topicKey=prim_ent/7995&selectedTitle=1~2&source=search_7995&selectedTitle=1~2&source=search_resultresult

• http://www.learningradiology.com/archiveshttp://www.learningradiology.com/archives04/COW%20096-Sialolithiasis/sialolithcorre04/COW%20096-Sialolithiasis/sialolithcorrect.htmct.htm

• http://www.emedicine.com/ent/http://www.emedicine.com/ent/topic598.htmtopic598.htm