Salivary Gland Stones.Care & specialists in Kuwait
In Kuwait, salivary Gland Stones is managed by ents. Salivary gland stones (sialolithiasis) are calcified concretions that form within a major salivary gland duct or parenchyma, obstructing saliva flow and producing the characteristic story of painful gland swelling that flares at mealtimes and settles between meals. Population-based prevalence is approximately 1 case per 10,000-30,000 per year (Escudier 2008; Lustmann 1990), with roughly 12 in 1,000 adults harboring asymptomatic small stones found incidentally on imaging.
Salivary gland stones (ICD-10: K11.5, sialolithiasis) are calcified deposits composed predominantly of calcium phosphate and calcium carbonate within an organic matrix of glycoproteins, mucopolysaccharides, and cellular debris. The condition results from a combination of saliva stasis, increased viscosity, alkaline pH, and a nidus (sloughed epithelium, bacteria, or food debris) on which mineral deposition occurs. The submandibular gland is preferentially affected because Wharton's duct is long (5-6 cm), curves upward against gravity, has a narrow papilla orifice, and produces mucinous saliva with relatively high calcium and bicarbonate. Parotid stones form within Stensen's duct or the gland parenchyma and tend to be smaller and multiple.
key facts
Prevalence
Annual symptomatic incidence 1 per 10,000-30,000 in Western populations (Escudier 2008); asymptomatic small stones in roughly 1.2% of adults on imaging series
Demographics
Male:female ratio approximately 2:1; submandibular stones account for 80-90%, parotid 5-20%, sublingual under 1%
Avg. age
Peak age 30-60 years; pediatric cases occur but are rare (under 5% of sialolithiasis)
Global cases
No reliable global figure; extrapolation suggests several million prevalent cases worldwide, with substantial under-diagnosis
Specialist
ENT
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How you might notice it
The key symptoms of Salivary Gland Stones are: Painful swelling of the affected gland that develops within minutes of starting a meal, peaks during eating, and gradually resolves over 1-2 hours (mealtime syndrome) — the most reliable clinical clue., Palpable hard mass under the jaw (submandibular) or in front of and below the ear (parotid) that may be tender on bimanual examination of the floor of mouth., Recurrent episodes of acute gland swelling with sour, gritty, or salty taste at mealtimes and intermittent pus from the ductal papilla., Visible stone protruding at the ductal orifice (Wharton's or Stensen's), especially in floor-of-mouth bimanual examination., Reduced salivary flow and a sense of dry mouth on the affected side as obstruction progresses., Acute bacterial sialadenitis with fever, erythema, induration, purulent discharge from the duct, and trismus, particularly when obstruction is prolonged or incomplete., Persistent firm gland on the affected side from chronic fibrosis, sometimes raising concern for tumor..
01Painful swelling of the affected gland that develops within minutes of starting a meal, peaks during eating, and gradually resolves over 1-2 hours (mealtime syndrome) — the most reliable clinical clue.
02Palpable hard mass under the jaw (submandibular) or in front of and below the ear (parotid) that may be tender on bimanual examination of the floor of mouth.
03Recurrent episodes of acute gland swelling with sour, gritty, or salty taste at mealtimes and intermittent pus from the ductal papilla.
04Visible stone protruding at the ductal orifice (Wharton's or Stensen's), especially in floor-of-mouth bimanual examination.
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How it’s diagnosed
diagnosis
Diagnosis is usually possible from history alone. The triad of recurrent mealtime swelling, post-prandial pain, and a palpable mass in the affected gland is highly specific for sialolithiasis. Bimanual examination of the floor of mouth — one finger inside, the other outside — palpates large submandibular stones and assesses ductal tenderness. Inspection of the ductal papilla may show a visible stone, purulent discharge, or stenosis. Once history and exam suggest stones, imaging confirms location, size, and number. Plain dental radiographs (occlusal view) detect approximately 80% of submandibular stones but only 60% of parotid stones because parotid stones are more often radiolucent. Ultrasound is the first-line imaging modality in most centers because it is non-invasive, available, and approximately 85-94% sensitive and 90-97% specific for stones over 2 mm (Brown 2016). Sialography — injection of iodinated contrast into the duct — was the traditional standard but is now replaced by MR sialography or CT sialography for non-invasive ductal mapping. Cone-beam CT detects radiopaque stones and small intraglandular stones. Diagnostic sialendoscopy (a 0.8-1.6 mm semi-rigid endoscope) is both diagnostic and therapeutic, performed under local or general anesthesia. Salivary scintigraphy and FDG-PET are reserved for atypical cases. Important differential diagnoses to exclude are salivary gland tumor (firm, persistent, non-fluctuant), Sjögren syndrome (bilateral, dry eyes and mouth, autoantibodies), and chronic recurrent juvenile parotitis (pediatric, no stones, sialectasis on imaging).
Key tests
01
Clinical history and bimanual examinationEstablishes the diagnosis of obstructive sialadenitis and often palpates large stones in the floor of mouth
02
Ultrasound of the salivary glandsFirst-line imaging; detects stones over 2 mm with 85-94% sensitivity and 90-97% specificity; assesses gland for fibrosis or abscess
✓Sialendoscopy with laser or pneumatic fragmentation
surgical options
Transoral sialolithotomyStone-free rate 90-98% for amenable stones; recurrence under 10% with hydration and sialogogue advice
Submandibular gland excision (sialoadenectomy)Cure of obstructive symptoms in over 95%; marginal mandibular nerve injury 1-8%, lingual nerve injury 1-4%, hypoglossal injury under 1% in experienced centers
Parotidectomy (partial or superficial)Cure of obstructive symptoms 90-95%; transient facial nerve weakness in 10-30%, permanent weakness in 2-5%
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Causes & risk factors
known causes
Salivary stasis in a slow-flowing, gravity-defying duct (submandibular)
Wharton's duct runs upward against gravity for 5-6 cm, has a narrow papilla, and drains a gland that produces viscous mucinous saliva. Slow flow allows mineral and organic material to accumulate on micro-niduses.
High mucinous content and alkaline pH of submandibular saliva
Submandibular saliva is more mucinous, richer in calcium, and slightly more alkaline than parotid saliva, favoring precipitation of calcium phosphate (hydroxyapatite, brushite) and calcium carbonate. This explains the disproportionate submandibular site predilection.
Dehydration and reduced salivary flow
Insufficient fluid intake, hot climates, diuretic use, and chronic systemic disease decrease saliva volume and increase concentration of stone-forming minerals. Patients with sialolithiasis often report low water intake.
Anticholinergic and xerogenic medications
Tricyclic antidepressants, antihistamines, antipsychotics, alpha-blockers, and diuretics reduce salivary flow and predispose to stone formation, particularly in older adults on polypharmacy.
Chronic sialadenitis from any cause
Recurrent infection, autoimmune (Sjögren syndrome), and post-radiation gland dysfunction create slow flow, ductal stenosis, and epithelial debris that act as stone niduses.
Gout and disorders of calcium and uric acid metabolism
Uncommon but recognized; some patients with recurrent stones have hypercalcemia, hyperuricosuria, or primary hyperparathyroidism. Screening is recommended in recurrent or multiple stones.
risk factors
Male sex
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Living with it
01Drink 2-3 L of water daily, more in hot climates or with diuretic medication.
02Use sugar-free citrus drops, gum, or vitamin C tablets at meals after a known stone episode to keep saliva flowing.
03Review medications with a clinician and reduce xerogenic drugs where possible.
04Stop smoking; tobacco reduces salivary flow and worsens sialolithiasis recurrence.
05Maintain meticulous oral hygiene to reduce ductal infection risk.
06Screen for hypercalcemia and hyperuricemia in patients with recurrent or multiple stones.
recommended foods
•2-3 L water daily, more in hot weather or with diuretic therapy
•Citrus fruits and sour fresh produce to stimulate saliva (lemon, kiwi, pineapple)
•Sugar-free chewing gum to maintain ductal flow between meals
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When to seek help
why see an ent
An ENT or oral and maxillofacial surgeon should evaluate any patient with recurrent gland swelling, palpable mass, or imaging-confirmed stone over 3-4 mm. Specialist input is essential to select between conservative therapy, sialendoscopy, ESWL, transoral removal, and gland excision.
Submandibular sialolithiasis (Wharton's duct)80-90% of cases. Stones tend to be radiopaque, often large (over 5 mm), and located in the duct (distal, hilar, or intraglandular). Classic mealtime swelling under the jaw is the typical presentation.
Parotid sialolithiasis (Stensen's duct)5-20% of cases. Stones are smaller (often under 5 mm), more often multiple, frequently radiolucent, and may be missed on plain radiographs. Pre-auricular swelling at mealtimes is typical.
Sublingual sialolithiasisUnder 1% of cases; presents with floor-of-mouth swelling. Often associated with ranula or minor-gland stones.
Acute obstructive sialadenitisStone causes rapid-onset gland swelling, severe pain at meals, and may progress to bacterial superinfection with fever, purulent ductal discharge, and overlying erythema.
Chronic obstructive sialadenitisRecurrent partial obstruction over months to years produces low-grade swelling, post-prandial discomfort, and progressive gland fibrosis with reduced saliva output and increased infection risk.
Living with Salivary Gland Stones
Timeline
Conservative management can clear small stones within 2-6 weeks. Sialendoscopy recovery: minor swelling 1-3 days; full normal eating within 1 week. Transoral sialolithotomy: 1-2 weeks of soft diet, full healing 2-4 weeks. Submandibular gland excision: 2-3 weeks off heavy work; small risk of marginal mandibular weakness improving over 3-6 months. ESWL: same-day return to activity, multiple sessions over weeks may be needed.
Lifestyle
01Massage the affected gland from posterior to anterior several times per day during flare-ups.
02Apply warm compresses to the gland for 10-15 minutes before meals during acute episodes.
03Sip water with each meal and chew thoroughly to maximize sialogogue effect.
04Avoid prolonged dehydration and high-salt fasting diets that thicken saliva.
05Maintain oral and dental hygiene including twice-daily brushing and flossing.
06Attend follow-up ultrasound at 3 and 12 months after stone removal to confirm clearance.
Daily management
01Drink water regularly through the day; aim for pale urine.
02Use sialogogues (lemon drops, sugar-free gum) at the start of each main meal.
Complementary approaches
Sialogogue drugs and sugar-free citrus candiesStimulate salivary flow, helping flush small stones and prevent recurrence. Pilocarpine or cevimeline are used in patients with concurrent hyposalivation.
Botulinum toxin injection for chronic recurrent sialadenitisSelected refractory cases of chronic sialadenitis benefit from intraglandular botulinum toxin to reduce salivary output and recurrent flares; emerging adjunct, not first line.
Choosing a doctor
Choose an ENT or oral and maxillofacial surgeon with formal sialendoscopy training and a personal annual volume of at least 30 cases. High-volume sialendoscopy units consistently report gland-preservation rates above 90%. For very large or intraglandular stones, ESWL availability is an additional advantage.
Salivary gland stones (sialolithiasis) are calcium-rich deposits that form in a salivary duct or gland and block the flow of saliva. They cause painful swelling that flares with meals and settles between them. About 80-90% form in the submandibular gland under the jaw; most can now be removed without taking out the gland.
What does a salivary stone feel like?▾▴
A salivary stone produces firm, painful swelling under the jaw or in front of the ear that comes on with eating, peaks during the meal, and gradually fades over 1-2 hours. Some patients describe a hard lump that can be felt with the tongue in the floor of mouth or with fingers behind the angle of the jaw.
What causes salivary stones to form?▾▴
Salivary stones form when saliva flow slows and minerals such as calcium phosphate precipitate around a nidus of debris or bacteria. Dehydration, mucus-rich submandibular saliva, anticholinergic medication, smoking, and chronic gland inflammation are the main risk factors. Gout, hypercalcemia, and hyperparathyroidism contribute in some recurrent cases.
How are salivary stones diagnosed?▾▴
Diagnosis combines history (mealtime swelling), bimanual examination of the floor of mouth, and imaging. Ultrasound is the first-line modality with 85-94% sensitivity. Plain dental radiographs detect most submandibular stones. Cone-beam or non-contrast CT, sialendoscopy, and MR sialography are used for difficult cases.
Can salivary stones go away on their own?▾▴
Yes — small stones under 3-4 mm can pass spontaneously in up to 50% of patients with increased hydration, sialogogues (sour candies), warm compresses, and gland massage. Larger or symptomatic stones usually need sialendoscopy, ESWL, or surgical removal to clear.
What is sialendoscopy?▾▴
Sialendoscopy is a minimally invasive procedure in which a 0.8-1.6 mm endoscope is passed through the duct opening in the mouth to visualize stones, stenoses, and inflammation. Small stones are retrieved with baskets or graspers; larger ones can be fragmented with a laser. The gland is preserved in over 90% of cases.
Is salivary gland surgery still needed?▾▴
Less often than before. Modern minimally invasive techniques preserve the gland in 80-95% of treated stones. Gland excision is reserved for deep intraglandular stones, end-stage fibrosis, or failure of endoscopic and transoral approaches. When surgery is required, recovery and nerve risks are well managed in experienced centers.
Can salivary stones cause infection?▾▴
Yes. Obstruction allows bacteria to ascend and cause acute sialadenitis with fever, redness, induration, and pus from the ductal opening. Deep-neck-space spread (Ludwig's angina from a submandibular abscess) is a medical emergency. Treatment is antibiotics, hydration, sialogogues, and drainage when an abscess forms.
Do salivary stones come back?▾▴
Recurrence is approximately 5-15% over 5 years after gland-preserving treatment. Risk is higher with persistent dehydration, smoking, anticholinergic medication, or untreated systemic conditions such as hypercalcemia and gout. Hydration, sialogogues, and lifestyle changes reduce recurrence substantially.
Are salivary stones dangerous?▾▴
Most are uncomfortable rather than dangerous, but untreated obstruction can lead to recurrent infections, chronic gland damage, abscess, and deep-neck-space spread. Persistent gland firmness or a non-fluctuating mass requires imaging and sometimes biopsy to exclude tumor.
How long does it take to recover from sialendoscopy?▾▴
Most patients return to normal eating within a week. Mild gland swelling and a metallic taste are common for 1-3 days. Driving and most desk work resume the next day; vigorous physical activity within 48-72 hours. Follow-up ultrasound at 3 and 12 months checks for residual or recurrent stones.
What is the success rate of ESWL for salivary stones?▾▴
Extracorporeal shockwave lithotripsy fragments stones up to 7 mm. Stone-free rates are 35-50% after one session and 60-80% after multiple sessions over weeks. ESWL is better for parotid than submandibular stones and is available in a limited number of centers worldwide.
Are there medications that prevent salivary stones?▾▴
No drug specifically prevents salivary stones. Hydration, sialogogues (citrus drops, sugar-free gum), smoking cessation, and review of anticholinergic medication reduce recurrence. In patients with hypercalcemia or hyperuricemia, treating the underlying cause lowers stone-formation risk.
Do salivary stones affect children?▾▴
Yes, although they account for under 5% of sialolithiasis cases. Pediatric stones are usually submandibular and managed with the same gland-preserving techniques. Recurrent parotitis in children is more often juvenile recurrent parotitis without stones and is treated separately.
Can I eat normally with a salivary stone?▾▴
Most patients can eat soft, well-hydrated foods with smaller bites. Sour or spicy foods often trigger the most pain at the start of a meal. After successful stone removal, normal diet resumes within 1-2 weeks. Long-term dietary restriction is not required.
Are salivary stones related to kidney stones?▾▴
There is a modest association in some studies, particularly with systemic disorders of calcium metabolism (hypercalcemia, primary hyperparathyroidism). Most patients with salivary stones do not develop kidney stones and vice versa, but recurrent stone formers should be screened for shared metabolic causes.
Why does the gland swell at mealtimes?▾▴
Eating stimulates saliva production; when a stone blocks the duct, saliva cannot drain, the gland distends, and pain develops within minutes. Once stimulation stops and saliva pressure falls, the gland gradually empties via leak around the stone and swelling resolves. The pattern is highly specific for stone obstruction.
Does smoking cause salivary stones?▾▴
Smoking reduces salivary flow, alters salivary composition, and is linked to higher rates of recurrent sialolithiasis in observational studies. Stopping smoking is one of the most effective lifestyle changes to prevent recurrence after stone removal.
Can salivary stones be left alone if they are not painful?▾▴
Small asymptomatic stones may be monitored, particularly in elderly patients with significant comorbidity. Symptomatic stones — pain, recurrent swelling, infection — should be treated to prevent progressive gland damage and abscess. Shared decision-making with an ENT specialist is appropriate.
What is the difference between sialolithiasis and sialadenitis?▾▴
Sialolithiasis is the presence of stones in the salivary system; sialadenitis is inflammation or infection of the gland, which can be caused by stones, viruses, or autoimmune disease. Most cases of obstructive sialadenitis in adults are caused by sialolithiasis.
How can I prevent salivary stones from returning?▾▴
Drink 2-3 L water daily, chew thoroughly, use sugar-free citrus drops at meals, stop smoking, review xerogenic medications, maintain oral hygiene, and treat systemic conditions such as gout or hyperparathyroidism. Follow up with ultrasound at 3 and 12 months after treatment to detect any new stone early.
05Reduced salivary flow and a sense of dry mouth on the affected side as obstruction progresses.
06Acute bacterial sialadenitis with fever, erythema, induration, purulent discharge from the duct, and trismus, particularly when obstruction is prolonged or incomplete.
07Persistent firm gland on the affected side from chronic fibrosis, sometimes raising concern for tumor.
08Foul taste in the mouth from intermittent purulent ductal discharge.
09Difficulty opening the mouth fully and tenderness on chewing in advanced cases.
10Asymptomatic detection on dental or ENT imaging in 1-2% of routine scans, often in older patients.
early warning signs
•A brief tightness or fullness under the jaw or in front of the ear that comes on with the first bite of a meal and settles afterward
•Intermittent sour or gritty taste when starting to eat sour or acidic foods (lemon, vinegar)
•Mild tenderness in the floor of mouth or pre-auricular region without obvious mass
•Occasional small white particle expelled into the mouth, particularly during chewing
•Recurrent mild swelling that resolves with massage of the gland or hot drinks
● emergency signs
•Severe gland swelling with fever above 38.5 °C, marked erythema, and induration — suspect bacterial sialadenitis or abscess requiring urgent antibiotics and possible drainage
•Floor-of-mouth swelling with elevation of the tongue and difficulty swallowing — exclude Ludwig's angina, a deep-neck-space emergency
•Marked trismus, drooling, and respiratory distress — possible deep-neck-space extension
•Unilateral firm parotid mass with facial nerve weakness — consider malignant tumor, not stone, and arrange urgent imaging and biopsy
•Persistent severe pain with poor response to oral antibiotics over 48-72 hours — admit for IV antibiotics and surgical drainage
Occlusal or panoramic dental radiographDemonstrates radiopaque stones in submandibular and parotid ducts; inexpensive and widely available
04
Cone-beam CT or non-contrast CT of neck/faceDetects nearly all radiopaque stones with precise location and size, including intraglandular and small stones
05
Diagnostic sialendoscopyDirect endoscopic visualization of the ductal system; identifies stones, stenoses, mucus plugs, and ductal changes; allows immediate treatment
06
MR sialography or CT sialographyNon-invasive ductal mapping when sialendoscopy is unavailable or stones are suspected in non-visualized branches; better than conventional sialography for radiolucent stones
07
Bloods for calcium, PTH, uric acidScreen for hypercalcemia, primary hyperparathyroidism, and hyperuricemia in recurrent or multiple stones
Outlook
Outlook is excellent in most cases. Stones under 3-4 mm pass spontaneously in up to 50% of patients with hydration and sialogogues. Gland-preserving techniques — sialendoscopy alone or combined with transoral or laser approaches — achieve stone-free outcomes in 85-97% of amenable stones and preserve the gland in over 90%. Recurrence rates after successful stone removal are 5-15% over 5 years and depend on hydration, smoking, medications, and presence of systemic risk factors such as hypercalcemia or gout. Submandibular gland excision is curative but removes the gland; long-term consequences include mild dry mouth on the side of surgery, generally well tolerated. Patient-rated quality-of-life scores improve substantially after gland-preserving treatment (Capaccio 2018). Diagnostic delay remains the main driver of poor outcome: prolonged obstruction leads to chronic fibrosis and the need for gland removal.
non-modifiable
Male:female ratio approximately 2:1 across most series, possibly reflecting differences in salivary composition and hydration patterns.
Age 30-60non-modifiable
Peak incidence in middle adulthood; pediatric and elderly presentations are less common but recognized.
Dehydration and low water intakemodifiable
Chronic mild dehydration concentrates saliva and increases stone formation risk. Athletes, outdoor workers, and patients on diuretics are particularly affected.
Smokingmodifiable
Cigarette smoking is associated with reduced salivary flow and increased ductal calcification in observational studies; quitting reduces recurrence risk after stone removal.
Xerogenic medicationsmodifiable
Anticholinergics, tricyclic antidepressants, antihistamines, antipsychotics, and diuretics reduce salivary flow and concentrate precipitates. Medication review is a low-cost preventive intervention.
Prior sialadenitis or salivary surgerymodifiable
Ductal stenosis from previous infection or instrumentation creates stasis that predisposes to new stone formation.
Disorders of mineral and uric acid metabolism increase risk of recurrent or multiple stones; screening with calcium, parathyroid hormone, and uric acid is recommended in recurrent disease.
•
Calcium and vitamin D from a balanced diet — there is no evidence that dietary restriction reduces stone formation
foods to avoid
•Sustained dehydration, excess alcohol, and high-caffeine beverages without compensating water intake
•Tobacco in any form
•Hard or sharp food during the acute phase, which can aggravate ductal trauma
•Anticholinergic over-the-counter medicines (some cold and motion-sickness drugs) without medical advice
01Sialendoscopy unit with at least 0.8 mm and 1.3 mm semi-rigid endoscopes and basket/grasper instruments
02Holmium or thulium intracorporeal laser availability for stone fragmentation
03On-site high-resolution ultrasound and cone-beam CT
04Oral and maxillofacial or ENT surgery cover for transoral and open procedures
05Multidisciplinary sialendoscopy case conference for complex stones
Essential facilities
Tertiary ENT and head-and-neck unitsOral and maxillofacial surgery departmentsSpecialized sialendoscopy centersSalivary gland disease clinics within otolaryngologyHospitals with ESWL programs for salivary stones
03Massage the affected gland 2-3 times daily during flare-ups.
04Inspect the ductal papilla for visible stones during oral hygiene.
05Track flares: time, food triggers, response to massage and warmth.
06Attend follow-up imaging or endoscopy as scheduled.
Exercise
Regular exercise is encouraged, with attention to hydration during prolonged exertion in heat. Avoid contact sports without a mouthguard for 2-4 weeks after intraoral surgery. Resumed normal activity within 24-48 hours after most sialendoscopy procedures.