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By Erik Paulson, D.O.

History
CC- 15 y.o. male c/o pain and swelling in jaw. Began yesterday, thought it might be strep

throat or something so he began taking left over Amoxicillin from last year. NKDA Seasonal allergies relieved by Claritin and Benadryl. No other meds Vaccinations up to date

Physical exam
Vitals- 101.2, 95, 16, 122/80 Swollen, tender and slightly erythematous
area on left side of neck just inferior to mandible. Decreased in size after pressure was applied.

Differential Diagnosis
Infection
Lymphadenitis Mono Strep Sialadenitis Mumps- vaccinations are up to date Stone Sjogrens Abscess

Neoplastic

Labs
CBC- Increased white count w/ left shift Rapid strep Mono spot All other labs normal

Diagnosis
Sialolithiasis with secondary sialadenitis

Quiz time
Duct from Parotid gland is called?
Stensens duct

Duct from Submandibular gland is called?


Whartons duct

Pathophysiology
Dehydration
Concentration of saliva

Fasting or Anorexia
Stasis of saliva

Drugs- Anti-histamines, Anti-cholinergics.


Decrease production of saliva

Stone can cause stasis of saliva and subsequent


bacterial ascent into the gland.
Infection most commonly from S. aureus or Strep Viridans.

Fun Facts about Sialolithiasis


Twice as common in males 1% incidence at autopsy Stones are usually made of calcium
phosphate

Treatment
Conservative
Warm compresses Sour candy Pain relief- Ibuprofen 800mg. PO Q8hrs PRN pain. Oral fluids Discontinue anti-histamines Oral antibiotics- Cefalexin 500mg PO QID X 7d.

Surgical

Lithotripsy

Wire basket retrieval under fluoroscopy. Duct cannulation Gland removal for recurrent cases

Osteopathic treatment
Gentle massage of the salivary gland may free
calculi that are near the end of the duct. It may also decrease the amount of saliva retained in the gland and provide symptomatic improvement. Lymphatic pumps to improve immune function. Increase/ normalize parasympathetic tone, decrease/ normalize sympathetic tone.

Outcome
Unknown, but he did not return to the ED
within the next two weeks.

References
http://0www.utdol.com.library.touro.edu/online/content /topic.do?topicKey=prim_ent/7995&selectedTitle =1~2&source=search_result http://www.learningradiology.com/archives04/C OW%20096-Sialolithiasis/sialolithcorrect.htm http://www.emedicine.com/ent/topic598.htm