Salivary stone disease

Salivary stone disease (synonyms: calculous sialadenitis, sialolithiasis) has been known for a long time. So, even Hippocrates connected the disease with gout. The term "salivary stone disease" was introduced by L.P. Lazarevich (1930), since he considered the process of formation of stones in the salivary glands as a disease.

Previously, salivary stone disease (SCD) was considered a rare disease. In recent years, it has been established that SKP is the most common disease among the entire pathology of the salivary glands; on its share, according to different authors, is from 30 to 78%.

Most often, the stone is localized in the submandibular (90-95%), rarely - parotid (5-8%) salivary glands. Very rarely, stone formation was observed in the sublingual or small salivary glands.

Differences in the frequency of occurrence of salivary stone disease on the basis of gender were not observed, while at the same time the disease was observed 3 times more often among urban residents than among the rural population. Children rarely get sick.

[1], [2], [3]

Causes of salivary stone disease

Salivary stone disease is a poly-tyological disease. At present, individual links of its pathogenesis are known. As is known, to the norm in the salivary glands there is a constant formation of microaliphytalites, which with a current of saliva freely wash out into the oral cavity.

At the heart of stone formation (Afanasyev VV, 1993) lie the presence. Congenital changes in salivary glands according to the type of local expansion (ectasia) of ducts of different caliber and a special topography of the main duct in the form of a broken line with sharp bends in which a calculus is formed. In these enlarged sections of the ducts, when the secretory activity of the gland is disturbed by the type of hyposialia, the saliva and micro-tissues accumulate and retard. Additional factors contributing to the formation of salivary stone and leading to growth of the calculus are: the presence of a violation of mineral, mainly phosphoric-calcium, metabolism; hypo- or avitaminosis A; the introduction of bacteria, actinomycetes or foreign bodies into the duct of the salivary gland; long-lasting chronic sialadenitis.

The rare formation of a stone in the parotid gland is due to the fact that its secretion contains statcherin, which is an inhibitor of calcium phosphate precipitation from the saliva.

Salivary stones, like all organomineral aggregates in the human body, consist of mineral and organic substances: organic matter prevails, amounting to 75-90% of the total mass. Alanine, glutamic acid, glycine, serine and threonine are predominant in the amino acid composition of the salivary stones. Such a composition of the organic component is generally similar to those in dental calculi. In the center of the stone, there is often a nucleus represented by organic matter, salivary thrombi, depleted duct epithelium, actinomycetes, and leukocyte accumulation. Sometimes foreign bodies serve as such a nucleus. The core of the stone is surrounded by a layered (lamellar) structure, in which spherical bodies are located. The occurrence of stratification in the salivary stones can be associated with daily, monthly, seasonal and other rhythms in the human body.

[4], [5], [6], [7]

Symptoms of salivary stone disease

Symptoms of salivary stone disease depend on the stage of the disease, the form and location of salivary stones, the state of the body and other factors.

The main and characteristic symptoms of salivary stone disease are pain and swelling in the area of the affected salivary gland during meals or at the sight of acute and salty foods, this symptom is called "salivary colic." The pain symptom is leading in the clinic of the disease. The literature describes a case of attempted suicide because of the pain that a patient had.

Depending on the location, shape and degree of mobility of the stone, pain can have a diverse character. If the stone is immobile and does not interfere with the outflow of saliva due to the presence of one or more grooves on its surface, then the pain may not be. Such a stone is called mute.

In the initial stage of salivary stone disease for a long period of time the disease develops asymptomatically. The stone is detected by chance, by radiographic examination of the patient for some odontogenic disease. The first symptoms of the disease appear when the outflow of saliva during eating, especially acid and acute ("salivary colic"), is disturbed. Patients report a periodic appearance of dense painful swelling in the area of the affected salivary gland. The appearance of pain during meals is associated with stretching the ducts of the gland because of their obstruction with a stone, which prevents saliva from flowing into the mouth. After eating, the pain and swelling gradually subside, and the secret of brackish taste is allocated to the oral cavity. Sometimes the pain is paroxysmal and does not depend on food intake. "Salivary colic" can be of different intensity.

Retention of the secretion is observed when the stone is located in the submandibular and parotid ducts or in the intragnular ducts. The secretion lasts from several minutes to several hours and even a day. Then it gradually passes, but it repeats during the next meal. The enlarged iron at palpation is painless, soft; When the stone is located in the gland, there is a compaction site. With bimanual palpation, but under the mandibular duct, a small delimited seal (stone) can be found. The mucous membrane in the oral cavity and in the mouth of the duct can be without inflammatory changes.

When probing the duct in the case of a stone in the anterior and middle sections of the submandibular duct, the rough surface of the calculus is determined.

If in the initial stage of the disease patients do not consult a doctor for a long time, the inflammatory phenomena increase and the disease passes into a clinically pronounced stage.

During this period of the disease, in addition to salivation retention symptoms, there are signs of exacerbation of chronic sialadenitis.

Exacerbation of the process in the presence of a stone in the duct or gland in some patients may be the first manifestation of the disease, since the stone is not always an obstacle to the outflow of saliva.

In this case, the symptom of "salivary colic" may not be.

Patients complain of the appearance of painful swelling in the hyoid or buccal areas, depending on the affected gland, difficulty in eating, raising body temperature to 38-39 ° C, general malaise. With an external examination of the patient, a swelling in the region of the corresponding gland is found. At a palpation the sharp morbidity in the field of a gland is defined. Sometimes there are signs of periadenitis, while a swollen swelling appears in the gland's circumference. When examining the oral cavity, hyperemia of the mucous membrane of the hyoid or buccal areas is determined from the corresponding side. At palpation it is possible to define a dense painful infiltration along the duct. With bimanual palpation under the mandibular duct can be probed in the form of a strand. As a result of significant infiltration of the duct walls, it is not always possible to establish the presence of a stone by palpation. In this case, in the course of the duct, a more compacted painful area is found at the location of the calculus. When pressure is applied to the gland or palpation of the duct, especially after probing it, a mucopurulent secret or thick pus is secreted from the mouth (often in a considerable amount).

Symptoms of salivary stone disease in the late stage

Sometimes in the anamnesis there is an indication of a repeatedly occurring exacerbation. With each aggravation of the process, changes in the gland grow, and the disease passes into the late stage, in which the clinical signs of chronic inflammation are expressed. Patients complain of constant swelling in the salivary gland, mucopurulent discharge from the duct, rarely signs of "salivary colic." In some patients, the gland is tightened gradually, without repeated exacerbation and retention of saliva. At survey it is possible to establish a swelling, delimited by the outside of the gland, dense, painless on palpation. From the excretory duct in the massaging of the gland, a mucus-like secret with purulent inclusions is secreted; the mouth of the duct is enlarged. When palpation along the course of the parotid or submandibular duct, its compaction is detected due to pronounced sialodochitis. Sometimes it is possible to determine the stone by the presence of a significant compaction in the duct and whether the gland and the simultaneous appearance of pain pricking. At the examination the decrease of the secretory function of the affected gland is determined. The cytological picture is characterized by accumulations of partially degenerated neutrophils, a moderate number of cells of the reticuloendothelium, macrophages, monocytes, sometimes - cells of the cylindrical epithelium in a state of inflammatory metaplasia; the presence of squamous epithelial cells. Sometimes goblet cells are defined. With a significant decrease in the function of the salivary gland in mucous contents, ciliated cells can be found. When the stone is located in the gland, in addition to these cells, cubic epithelial cells are found.

Classification of salivary stone disease

In clinical practice, the most convenient is the classification proposed by IF. Romacheva (1973). The author singled out three stages of the development of the disease:

1. initial, without clinical signs of inflammation;
2. clinically pronounced, with periodic exacerbation of sialadenitis;
3. late, with severe symptoms of chronic inflammation

The stage is determined by the peculiarity of the clinical picture and the results of additional research methods. Particular attention is paid to the functional condition of the salivary gland and the severity of pathological changes in it.

[8]

Diagnosis of salivary stone disease

In recognition of salivary stone disease, it is important not only to establish the presence, localization, size and configuration of concrements, but also to identify the cause of stone formation, as well as predisposing to it and relapse conditions. At the same time, it is necessary to determine the functional state of the salivary gland.

General, private and special methods are used to diagnose salivary stone disease.

An important anamnestic sign of salivary stone disease is an increase in the salivary gland during meals. With the help of bimanual palpation, it is sometimes possible to determine the stone in the thickness of the submandibular gland or along the course of its duct. Small stones are probed only near the mouth of the duct. The submandibular duct must be palpated, moving the fingers from behind in advance, so as not to dislodge the suspected concrement into the ductile part of the duct. If the stone is located in the anterior part of the parotid duct, then it is palpated on the side of the mucous membrane of the cheek; with pre-mass and localization it can be detected from the skin.

In bimanual palpation, the compaction in the gland can be determined not only by the presence of stone, but also by chronic infection, phlebolitis, inflammation of the lymph nodes, amyloidosis, polymorphic adenoma.

Probing the duct allows you to identify the stone and determine the distance to it from the mouth. Contraindication to the sounding (due to the possible perforation of the duct wall) is the presence of exacerbation of sialadenitis. For probing, salivary probes of different diameters are used. They have a flexible working part and a different diameter, which greatly facilitates sounding and allows to determine the diameter of the mouth of the excretory duct.

The leading role in the recognition of salivary stone disease belongs to the radiation methods of investigation (X-ray diffraction, sialography, etc.). Usually, the research begins with an overview X-ray of the gland. Survey radiography of the parotid gland is carried out in a direct projection. In the lateral projection, the salivary stone can be difficult to detect because of the imposition of the shadows of the bones of the skull. For X-rays of the anterior part of the parotid duct, the X-ray film is placed on the threshold of the mouth in the mouth area, and the X-rays are directed perpendicular to the cheek surface.

For radiographing of the submandibular gland, use a lateral projection or a method proposed by V.G. Ginzburg in the 1930s, in which the film is applied to the skin in the submandibular region from the affected side, and the x-rays, at the maximum open mouth, are directed from the top downwards and toward the affected gland between the upper and lower jaws. To reveal the stone in the anterior part of the submandibular duct, radiography of the bottom of the oral cavity, proposed by A. A. Kyandsky, is used.

To identify the salivary stone located in the posterior part of the submandibular duct, an x-ray lining is used to examine the tissues of the bottom of the oral cavity. For this, the patient is treated with a soft palate with a 10% solution of lidocaine before the examination, the X-ray film is placed in the mouth between the teeth before touching the soft palate, the patient folds the head as far back as possible, and the X-ray tube is placed on the patient's chest from the affected side. With the help of this technique, it is possible to identify a stone located in the intragnular part of the submandibular duct.

It is not always possible to detect shadows of concrements on survey X-rays. Often, the shadow of the stone is superimposed on the bones of the facial skeleton. In addition, the stones can be x-ray contrast or low contrast, depending on their chemical composition. Given by I.F. Romacheva (1973), V.A. Balode (1974), radioconjugated salivary stones occur in 11% of cases.

To improve the diagnosis and identify the stone VG. Ginzburg proposed a sialogram. For sialografii it is better to use water-soluble radiocontrast agents (omnipac, trazograph, urographine, etc.), since they less injure the gland. Sialography makes it possible to identify radiocontrast salivary stones, which on sialograms look like defects in filling the duct.

On the sialogram, a uniform expansion of the ducts is revealed posteriorly from the location of the stone. The contours of the ducts are even and clear in the initial period of the disease; the greater the number of exacerbations suffered by the patient, the more deformed the ducts. The ducts of the gland of I-III orders can be enlarged, deformed and interrupted. Sometimes the contrast medium fills the ducts unevenly. The parenchyma of the gland is not clearly defined or determined, depending on the stage of the process. In the case of an X-ray contrast stone, it is detected as a filling defect.

Echosialography is based on different degrees of absorption and reflection of ultrasonic waves by different tissues. The stone reflects ultrasonic waves, creating a picture of an acoustic shadow or a sound track, the width of which can be judged on its size.

[9], [10], [11], [12]

Pathomorphological examination

In the cytological study of the secret in the case of the location of the stone in the gland on the cytograms neutrophilic leukocytes predominate, partly in the state of necrobiologic destruction, a large number of erythrocytes, which indicates a trauma of the protocol epithelium with a stone. Cylindrical epithelium is found by accumulations and separate specimens, cells of flat epithelium - in a moderate amount. When the stone is located in the duct, the cellular secretion is much scarcer, there is no cylindrical epithelium, more cells of the flat epithelium are noted. With the exacerbation of the process, regardless of the location of the stones, the number of cellular elements increases. The data of the cytological study of the secretion of the gland must be compared with the data of other methods of research.

Usual and multispiral computer sialotomography is used to identify and establish the spatial location of the salivary stone, which is necessary when choosing a method of treatment. Computer sialotomography can also detect radiocontrast stones. Modern computer tomography allows you to create a three-dimensional model of tissues of a given density.

Differential diagnosis of salivary stone disease should be carried out with noncalceral acute and chronic sialadenitis, malignant gland tumors, cysts, lymphadenitis, mandibular osteoma, phlebolitis, petrophytes of lymph nodes in tuberculosis, etc. A typical anamnesis and objective survey data allow in most cases to correctly diagnose.

Treatment of salivary stone disease

Treatment of salivary stone disease is not only in removing the calculus, but also in creating conditions that prevent the relapse of stone formation.

The location of the salivary stone in the intracerebral ducts is often the reason why doctors remove the salivary gland along with the stones.

The operation of removing the salivary gland, especially the parotid gland, is a rather difficult task; it is associated with the risk of complications such as injury of the branches of the facial, lingual and hyoid nerve, leaving the stone in the duct cult or in surrounding tissues. Poorly bandaged stump of the duct can further serve as a source of infection.

It is known that the salivary glands play an important role in the human body as an organ of exocrine and endocrine secretion. After the removal of one of the major salivary glands, its function is not restored at the expense of the others. Studies have shown that after the removal of the salivary glands, especially the submandibular, various diseases of the gastrointestinal tract develop, such as gastritis, colitis, gastroduodenitis, cholecystitis, etc. Therefore, the extirpation of the salivary gland in patients with salivary stone disease is undesirable.

Conservative treatment of patients with salivary stone disease is ineffective and is used mainly for the location of small stones near the mouth of the duct. To this end, the patient is prescribed substances that stimulate salivation. Thus small stones can be thrown out by a current of a saliva in an oral cavity. The purpose of salivary preparations should be combined with preliminary flowering of the duct.

Some authors recommend the following technique, called "provocative test". At small sizes of the calculus (0.5-1.0 mm), the patient is given 8 drops of 1% pilocarpine hydrochloride solution inside. At the same time, bore the mouth of the excretory duct with a salivary umbrella as large as possible and leave it in the duct as an obturator for 30-40 minutes. The probe is then removed. At this time, from the widened mouth of the duct, a large amount of secretion is allocated and together with it a small stone can stand out. However, this method rarely succeeds.

I.I. Cecina (2010) developed a method of conservative treatment of salivary stone disease. The author suggested injecting 0.5-1.0 ml of 3% citric acid solution into the excretory duct of the salivary gland daily for 10 days. At the same time, the patient is prescribed the following medicinal complex: Kanefron H 50 drops 3 times a day; 3% potassium iodide solution on a tablespoon 3 times a day; infusion of herb sprouts on 1/4 cup 3 times a day. The course of treatment 4 weeks. In the last week of treatment, oral intake of a 3% solution of potassium chloride is replaced by ultrafast phonophoresis. The courses are repeated after 3 and 6 months. According to I. I. Chechina, stones of small size can independently come out or shrink in size, which prevents the development of "salivary colic". This method may be alternative, but in most cases can not replace the surgical removal of the calculus.

Operations with salivary stone disease

If the stone is located in the parotid or submandibular ducts, as well as in the parenteral ducts of the parotid gland, surgical removal of the stones is indicated. If the stone is located in the intragnular ducts of the submandibular gland, then remove the gland along with the stone.

Removal of stones from the submandibular and parotid ducts is performed on an outpatient basis. Removal of stones from the intra-iron parts of the parotid gland and extirpation of the submaxillary salivary gland are performed in a hospital.

When the stone is located in the anterior part of the parotid duct, it can be removed by intraoral access by means of a linear incision of the mucous membrane of the cheek - along the line of teeth closing or semi-ovoid incision and scraping the flap bordering the mouth of the duct, according to the method of Afanasyev-Starodubtsev, if the stone is located on average or posterior parts of the parotid duct.

When the stone is located in the distal parts of the parotid duct, it can be removed by intraoral access using a curettage spoon, introduced to the anterior margin of the parotid salivary gland after dissection of the duct.

In the case of the location of the calculus in the parotid gland, it is removed by the extraoral method by folding the skin-fat flap according to the Kovgunovich-Klementov method.

When the salivary stone is located in the anterior and middle sections of the submandibular duct, it is removed by intraoral access using a linear or tongue-shaped incision in the hyoid area. After removal of the stone, it is advisable to form a new mouth of the duct according to our method (Afanasyev VV, Starodubtsev BC) for better separation of the secret in the subsequent.

In the case of salivary stone disease and a significant expansion of the intraluminal part of the parotid duct (up to 1 cm in diameter), we use the following procedure: an external incision is made, according to Kovtunovich-Khlementov, and the skin-fat flap exfoliates, and the parotid gland is exposed. The parotid duct is parched during its dilated part. The duct dissected along the entire length and at the ends is dissected by transverse incisions. After the opening of the duct, the medicinal sanitation of the ducts and removal of the calculi are performed. Formed flaps of ducts are screwed inward and sutured to its internal part. At the outlet of the duct, it is bandaged to discharge the gland function.

Eliminate the salivary gland is necessary only in cases of frequent recurrence of the disease and the lack of the possibility of surgical removal of the stone.

Complications after surgery with salivary stone disease

During and after surgical treatment of patients, a number of complications may develop.

External salivary fistulas usually develop after removal of the stone by external access from the parotid gland. Fistulas present certain difficulties for the surgeon. To close them, a number of operations are proposed.

The branches of the facial nerve can be damaged by interfering with the parotid salivary gland. Disturbance of conduction in them can be persistent at the intersection of the nerve and temporary - when it is compressed with swollen tissues.

When removing the submandibular salivary gland, the marginal branch of the facial nerve can be damaged, which leads to a loss of the tone of the triangular muscle of the lower lip.

Damage to the lingual or hyoid nerve can occur when removing the submaxillary salivary gland or during the removal of the salivary stone through access to the maxillofacial groove. In this case, a persistent loss of sensitivity of half the tongue can develop.

Cicatricial narrowing of the ducts often occurs after removal of the stone. Often they are formed in those cases when the removal is made during the exacerbation of salivary stone disease. For the prevention of cicatricial narrowing of the duct after removal of the stone is recommended the creation of a new estuary. When forming scar scarring in the duct, it is necessary to perform a plastic operation to create a new mouth of the duct back to the place of narrowing according to the method of Afanasyev-Starodubtsev. If this can not be done, the operation of removing the salivary gland is shown.

Surgical treatment of patients with salivary stone disease is traumatic, after the removal of the stone, complications are possible. Often the recurrence of recurrence is forced to resort to repeated interventions in already more difficult conditions. These problems, as well as the lack of effective conservative methods of treating patients led to the development of extracorporeal shock wave lithotripsy, or remote lithotripsy (DLT), which in recent years has become an alternative to traditional methods of treating patients with salivary stone disease.

For the fragmentation of salivary stones using apparatus-lithotripter Minilith, Modulith Piezolith and others.

The essence of the DLT is that the stone is crushed by shock waves. Treatment with the use of the method of DLT can be carried out if the stone is located in the intragnular part of the submandibular duct and in all parts of the parotid. A prerequisite for the conduct of EBT is a good outflow of secretion from the gland (no stricture of the duct in front of the stone) or the possibility of creating an outflow surgically. Limitations for the use of DLT depending on the size of the stone there. The method of shock-wave sialolithotripsy in the Russian Federation was elaborated in detail by M.R. Abdusalamov (2000), later on Yu.I. Okonskaya (2002) confirmed the author's conclusions about the effectiveness of the technique of stone crushing. Not all the stones undergo crushing. Thus, V. V. Afanasyev et al. (2003) found that soft stones, mostly containing organic elements, are not easily crushed. Solid stones can be crushed in different modes.

Recurrences of stone formation can occur both after the salivary stone separates itself, and after surgical removal or with the help of DLT. The cause of relapse may be the body's tendency to stone formation and the leaving of stone fragments in the duct after surgical intervention or crushing. In these cases, the removal of the salivary gland is recommended.

[13], [14], [15], [16]