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It’s been another busy night, mostly flu patients but a few other scattered maladies and injuries to keep life interesting. The next case, for instance, doesn’t sound much like flu. The nurse has just put a 15-year-old boy in bed 10 with a complaint of fever and facial swelling. Variety is the spice of life. Off you go to check him out.

He gives a history of three days of pain and swelling in the right lower face and under the jaw line on the right side. He’s had some fevers up to 101. The pain and swelling have been getting progressively worse. He denies toothache. He doesn’t recall any trauma or break in the skin in the region.

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His past medical history is unremarkable. He doesn’t take any routine medications, just ibuprofen for the pain in his lower face and jaw. He’s never had anything like this before. When you ask him if his pain and swelling have any association with mealtimes he gets quiet for a minute and then nods. In fact, the first time he noticed this was at dinner.
On to the exam. His vitals are unremarkable, he just took some ibuprofen and has no fever right now. Looking at him, he has swelling on his right side, primarily in the submandibular region. It’s slightly red, warm and very tender. You have him open his mouth. You start by inspecting the teeth, looking for a cavity or something but they look fine. Then he lifts his tongue and you hit pay dirt.

You find a small stone sitting in the opening to the duct of the right submaxillary gland (Wharton’s duct). You tentatively touch it with your tongue blade and it flicks right out. Behind it, you can see a little pus oozing out of the duct. The patient already says he is beginning to feel better. On gentle palpation, you don’t feel any other stones.

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The stone (left) was easily removed, leaving behind an enflamed opening to Wharton’s duct (above). The stones are due to calcium and phosphate crystals that typically accumulate when the water content of the saliva is low.


So what’s with the rock in Wharton’s duct? Patients can develop salivary duct stones at any age, although most occur in adults. The condition is known as sialolithiasis. Wharton’s duct, which drains the submaxillary gland, is the most common site for stones. About 15% of stones form elsewhere, about 10% in Stenson’s duct (which drains the parotid gland in the cheek) and 5% in the sublingual ducts. The stones are due to calcium and phosphate crystals that are most likely to accumulate when the water content of the saliva is low, such as in dehydration or with medications that dry out your spit, such as antidepressants, antihistamines or diuretics.

Patients with stones will experience pain and swelling in the affected gland. This will worsen at mealtimes or if the patient eats something acidic that stimulates salivary flow, such as a pickle. The saliva may feel gritty or have a funky taste. Sometimes these symptoms last a few hours and subside. If the duct is blocked by the stone, infection of the gland can occur. The gland may become swollen, tender, or red and the patient may develop fever.

Frequently, the diagnosis can be made by the history and exam, as in this patient. Sometimes, if a stone is suspected but not visualized, imaging may be helpful. A dental film that is shot at a right angle to the floor of the mouth may pick up a stone in Wharton’s duct. Alternatively, ultrasound or CT may be helpful. It is useful to keep in mind that 25% of stones are multiple.

If you see a stone, try to remove it, or gently milk the duct to see if it can be expressed. If not, an ENT referral is warranted. After the stone is out, review the patient’s medications to see if they are taking anything that dries out the saliva. Have them increase the amount of water they drink. Ask the patient to suck on sour candy or vitamin C tablets, which will stimulate salivary flow in the ducts. If the gland is infected, start them on a course of antibiotics such as cefalexin or dicloxacillin.

Remember, if you don’t think of it, you can’t diagnose it. When there is swelling of the salivary glands, go check out the ducts. Happy duct hunting.

Amy Levine, MD, is an associate professor of pediatric EM at UNC Chapel Hill 
 
Other causes of swelling of the salivary glands:
MUMPS – Usually affect parotid glands. Fever & other symptoms occur prior to gland swelling.
AIDS, Sjogren’s syndrome, sarcoidosis, diabetes mellitus – Should have other findings besides salivary gland swelling.
Cancer of the gland – Swelling usually firmer than that caused by infection.
Accidental biting injury – May harm a salivary gland and prevent the flow of saliva. The affected gland may swell and form a bluish, small, soft lump known as a mucocele.
 

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