Mouth dryness may be due to stones in salivary gland
BHUBANESWAR: Bibek Mohanty* would feel a painless lump in the submandibular gland (located below the jaw) whenever he took spicy food and it would disappear within a few hours. Panicked at the recurrent swelling of the left submandibular gland, he consulted doctors at a Bhubaneswar-based hospital.
The youth, who was suffering from salivary gland disorders, could not believe what the surgeons at the hospital stumbled upon during diagnosis. He was carrying over two dozen stones in the submandibular duct.
“After the diagnosis, 27 stones were retrieved using laser dormia basket by sialoendoscopy, which is a minimally invasive procedure to diagnose and treat salivary gland disorders. The gland became functional again after the procedure was done,” said Dr Radhamadhab Sahu, head of ENT and skull base surgery at SUM Ultimate Medicare.
Salivary glands in the human body play a crucial role in overall oral health. The glands produce 0.5 to 1.5 litres of saliva, a complex mixture that helps keep the mouth moist to make chewing, swallowing and speaking easy, lubricating food so it can move smoothly through the digestive tract and protecting against infections.
There are three sets of major salivary glands - the parotid glands are the largest and are located beneath and in front of the ears; the submandibular glands are the second largest and are located under the lower jaw; and lastly the sublingual glands, which are smaller and found underneath the tongue.
Besides the three major glands, there are 600 to 1,000 very tiny, minor salivary glands scattered throughout the mouth and throat. They are located under the moist skin that lines the inner lips, inner cheeks, palate, back of the throat, back portion of the tongue and pharynx. People suffer from salivary gland disorders when something blocks one or more glands preventing them from producing or releasing saliva. Various disorders and tumours can affect salivary glands, leading to discomfort and potential complications.
Disorders include common salivary gland infections, viral infection, salivary gland stones (sialolithiasis), sialadenitis, sialadenosis, cyst, Sjogren's syndrome, mucoceles and salivary gland tumours. Dr Sahu said sialolithiasis has been reported as the most common cause of salivary ductal obstructions, strictures and mucous plugs as the rare foreign body can cause significant obstruction to ductal flow.
“The majority of obstructive salivary gland diseases can be attributed to the presence of stones or sialoliths. Almost 60-70% of reported obstructive salivary disease comprises sialolithiasis, which occurs in about 1.2% of the population. Amongst the major salivary glands, the submandibular is the most affected (87%), followed by the parotid (10%) and the sublingual (3%),” he said.
Symptoms and diagnosis
Symptoms vary, depending on the specific type of salivary gland disorder. In sialolithiasis, the most common symptom is a painful lump in the affected gland under the tongue. Pain may worsen during eating. It will lead to salivary gland swelling, strange taste, difficulty in swallowing, trouble in opening mouth, dry mouth (xerostomia) and facial pain or swelling, usually under the jaw or around the ear.
The symptoms of sialadenitis include a tender, painful lump in the cheek or under the chin, a foul-tasting discharge of pus from the duct into the mouth and in severe cases, it leads to fever, chills and general weakness. The highest risk of complications is in elderly people and those with chronic, debilitating illnesses.
While cyst causes a painless lump, it sometimes grows large enough to interfere with eating. A slow-growing lump is the most common symptom of both cancerous and noncancerous salivary gland tumours. It can be found in the cheek, under the chin, on the tongue or on the roof of the mouth. The main features of Sjogren's syndrome are swelling of salivary glands, dry eyes and a dry mouth besides joint pain, which is also common.
Similarly, sialadenosis, which is an uncommon non-inflammatory condition, typically causes painless swelling of the parotid glands on both sides of the face. The most common causes are chronic alcoholism, diabetes and obesity. There are also other incriminated conditions like malnutrition, bulimia or drugs.
“Sialadenitis is usually caused by a bacteria like staphylococcus aureus and sometimes by virus (mumps) or fungal infection. The cause of infection is commonly blockage of the duct, impairing saliva secretion and leading to stasis and superadded infection. The presence of stones, known as sialolithiasis in the duct or ductal stricture is evaluated by radiology.
Rare autoimmune disorders could present with sialadenitis like Sjogren syndrome. Sometimes, non-infective and non-inflammatory gland swelling known as sialadenosis can occur, with no symptoms due to alcoholism, diabetes, etc,” said Dr C Preetam, professor of ENT, AIIMS, Bhubaneswar. Depending on the symptoms, history and physical findings, doctors usually advise some tests, including blood tests to look for a high white blood count that would suggest a bacterial infection.
Treatment options
The treatment can vary from just patient being taught milking of duct to Sialendoscope and procedures done through it including the dilatation to calculus removal or in nonresponding cases, removal of calculus by open technique to removal of gland itself. Sialadenitis is treated based on the underlying cause of the infection. If the infection is caused by bacteria, then antibiotics will be the treatment of choice.
Medication to stimulate more saliva secretion also helps. Since sialadenitis is caused due to decreased salivary flow, the patients are advised to drink plenty of fluids or eat foods that increase the salivary flow, like candies or lemon juice. For sialolithiasis related sialadenitis, sialendoscopy is the treatment of choice.
“Sialoendoscopy is a minimally invasive procedure to diagnose and treat salivary gland disorders including stones, strictures, chronic inflammation and other problems affecting major salivary glands,” said Dr Sahu. “Sialoliths with sizes ranging between 3-4 mm are amenable for endoscopic retrieval and can be retrieved using a wire basket.
For stones between 4-8 mm, holmium laser is used to break the stones into small particles and are taken out with a basket. A sialoendoscopic guided combined approach is planned for very large stones more than one cm to remove the stone and save the gland,” Dr Sahu added.
However, the risk of viral infections of the salivary glands can be reduced through immunisation against mumps and influenza. It is always helpful to avoid smoking, eat a healthy diet, drink adequate water and practice good oral hygiene with regular brushing to prevent chronic sialadenitis.
*Name changed