Sialolithiasis
| Classification according to ICD-10 | |
|---|---|
| K11.5 |
Sialolithiasis Sialolite |
| ICD-10 online (WHO version 2019) | |
As Sialolithiasis ( Greek .: σίαλον, sialon , saliva '; λίθος lithos , stone', -ίασις - iasis , morbid condition ') refers to the salivary stone formation in analogy to urolithiasis and cholelithiasis , which hinders the outflow of the saliva and a secondary sialadenitis (Inflammation of the salivary gland) or sialodochitis (inflammation of the salivary duct).
Etiology and pathogenesis
The etiology and pathogenesis of sialolithiasis have not yet been conclusively clarified. In addition to local factors, general illnesses (dehydration), reduced saliva flow, changes in the composition of the saliva (pH shifts, increase in calcium concentration), luxury food consumption (nicotine abuse), primary hyperparathyroidism and the penetration of bacteria and food residues into the saliva ducts are among the recognized risk factors for a Stone formation. A causal connection with systemic diseases or other stone disorders, such as kidney stones , has not yet been proven. Salivary stones are most frequently located in the submandibular gland (mandibular salivary gland , approx. 83%), far less often in the parotid gland (parotid gland, approx. 10%) and in the sublingual gland ( sublingual gland, approx. 7%). The reason for the different distribution is, on the one hand, that the saliva of the mandibular pancreas contains significantly more calcium and phosphate than the saliva of the parotid gland and is a relatively viscous secretion. The calcium is responsible in particular for the remineralization of the teeth, which is also visible in the preferential tartar formation on the lingual surfaces of the lower anterior teeth . On the other hand, the long, winding and ascending course of the duct (Wharton's duct) seems to play a role in its development. Lips and cheek are the preferred locations for the rare salivary stones of the small salivary glands .
Morphology and localization
The stones consist of a central organic matrix of glycoproteins, mucopolysaccharides, lipids and cell debris from bacteria and the duct walls with concentric inorganic deposits, predominantly of calcium phosphate (e.g. brushite , apatite , dahllite , whitlockite , hydroxyapatite and weddellite ). In the case of submandibular stones, the inorganic part outweighs the organic part by far at approx. 81%. The stones of the submandibular gland are located in the intraparenchymal duct system in 9% of cases, in the hilum area in 57% and in the distal duct system in 34%. In comparison, 23% of the stones in the parotid gland lie in the intraparenchymal duct system, 13% in the hilum area and 64% in the distal ductus stenon.
Clinic / symptoms
Most patients report recurring, painful swellings in the area of the affected gland. A very characteristic of a saliva drainage disorder is a close temporal relationship between the stimulation of saliva production, for example through food intake, and the occurrence of the symptoms. About half of the patients complain of swelling that is associated with pain, only about 45 percent notice swelling, only about 3.3 percent report pain without recognizable swelling; the remaining 0.7 percent are discovered accidentally during examinations for other reasons, for example during a dental x-ray. If acute inflammation develops, there may be a discharge of pus in the oral cavity and, in extreme cases, an abscess inside the gland. Since usually only one of the large salivary glands is affected, a dry mouth is not one of the symptoms caused by a stone disease.
Diagnosis
The diagnosis begins with the clinical examination, whereby the assessment of the saliva and palpation of the oral cavity are the most important. The most important and often sufficient imaging procedure is sonography. The advantages of sonography are the immediate availability, the lack of radiation exposure and invasiveness and the low acquisition costs of the devices compared to large devices such as MRI or CT. This means that approx. 97% of the stones with a size of 1.5 to 3 mm can be detected. Another important method is magnetic resonance imaging (MR sialography), with which fluid-filled cavities can be displayed very well. It works without contrast media and X-rays and allows very good soft tissue imaging and has therefore largely replaced X-ray sialography, which was often used in the past. Other imaging methods such as conventional sialography, computed tomography (CT), salivary gland scintigraphy or conventional X-rays are only reserved for special questions or are indicated for random diagnostics. In the last 25 years, a direct salivary duct specimen (sialendoscopy) has established itself as a further procedure: it is carried out with miniaturized, semi-rigid endoscopes with integrated irrigation, working and light channels. Endoscopy enables stones, duct strictures and inflammatory changes to be visualized directly. In addition to diagnosis, immediate therapy is possible: pliers, drills, dilatation balloons, laser conductors and stone baskets can be inserted into the passage through a working channel and larger stones can be smashed and smaller ones removed directly.
Conservative treatment
During the initial treatment, the wait-and-see attitude is in the foreground if there are no symptoms. In the case of complaints due to a stone, conservative therapy methods - such as acid drops, hydration, glandular massage, antibiotics and cold application - are initially used. As a result, small stones or stone fragments should be flushed out, possibly supported by the expansion of the duct with a probe. Antibiotics are used in acute inflammation caused by saliva congestion. Only after unsuccessful conservative therapy can the surgical procedures be considered; Here the minimally invasive procedures, whose maxim is the structural and functional preservation of the diseased gland, are in the foreground.
Minimally invasive treatment
Analogous to the removal of urinary stones, the salivary stone can also be removed by means of extracorporeal shock wave lithotripsy (ESWL). It is one of the oldest gland-preserving procedures and is now scientifically supported by long follow-up examinations in large case series. The stones are broken up with an electromagnetic lithotripter (usually three treatments with 3000 pulses at least four weeks apart). parotis and from 12-63% in the case of Eq. Achieve submandibular and symptom-free rates of up to 83% and 94%, respectively. In interventional salivary ductoscopy, stones are disintegrated and removed using forceps, baskets, drills, balloons or a laser, and narrowed duct areas are expanded. In addition, this procedure can improve the success rate of extracorporeal shock wave lithotripsy (ESWL), since small remaining calculus can be removed from the duct system after an ESWL treatment.
Operative treatment
Surgical treatment is possible under local or general anesthesia . In the simplest case of duct slitting, a probe is inserted into the salivary duct, whereby the salivary duct can be clearly displayed. The salivary duct is then opened with an incision over the stone and the stone removed. In individual cases, the edges of the wound can be sutured to the surrounding area in order to prevent scarred constriction of the salivary duct. Alternatively, a thin tube is temporarily inserted into the saliva duct. Surgical stone removal is also possible in combination with a salivary ductoscopy if stones are located very far in the glandular body. The light from the endoscope then shows the way to where the stone can be retrieved through a small incision in the floor of the mouth or from outside the ear. If none of the above procedures are successful, the affected gland is finally removed as parotidectomy in the case of the parotid gland or submandibulectomy in the case of the mandibular gland. Now that all conservative and minimally invasive techniques have been exhausted, this is only necessary in a few cases.
Complications
Manipulating the salivary ducts can lead to bleeding and scarred constriction of the salivary duct. Disinfectants rarely cause redness, irritation and inflammation. In very rare cases, if a salivary gland inflammation persists or if minimally invasive salivary stone removal fails, the entire salivary gland must be removed. Then injuries to neighboring sensitive or sensory nerves (cutaneous nerves, tongue nerve) with corresponding loss of feeling and taste or of motor nerves (facial nerve) with paralysis in their supply area, e.g. B. the corner of the mouth.
swell
- Salivary stone disease
- ↑ Salivary duct stones, Medline. Retrieved February 8, 2016.
- Maxillofacial surgeon. Volume 8, Issue 3, September 2015, pp. 128–141.
- S2k guideline "Obstructive Sialadenitis" of the German Society for Ear, Nose and Throat Medicine, Head and Neck Surgery, Bonn, AWMF Register No. 017-025
Individual evidence
- ^ BC Stack, Jr., JG Norman: Sialolithiasis and primary hyperparathyroidism. In: ORL J Otorhinolaryngol Relat Spec. 70 (5), 2008, pp. 331-334.
- ↑ a b c d e C. Sproll, C. Naujoks: Inflammation and obstructive salivary gland diseases. In: Maxillofacial Surgeon. 8, 2015, pp. 128–141.
- ^ H. Iro, J. Zenk: Concepts for diagnosis and therapy of salivary stone disease. In: Deutsches Ärzteblatt. 100 (9), 2003, pp. A-556 / B-475 / C-448.
- ^ C. Sproll: Salivary stone diseases . 2016; Available from: www.speichelstein.de
- ^ P. Katz: [Endoscopy of the salivary glands]. In: Ann Radiol (Paris). 34 (1-2), 1991, pp. 110-113.
- ↑ H. Iro et al .: Outcome of minimally invasive management of salivary calculi in 4,691 patients. In: Laryngoscope. 119 (2), 2009, pp. 263-268.
- ↑ J. Zenk et al: [The significance of extracorporeal shock wave lithotripsy in sialolithiasis therapy]. In: ENT. 61 (4), 2013, pp. 306-311.
