You’re minding your own business
one day--eating salty snacks while watching football, drinking beer and eating
pizza and pretzels while kibitzing with your friends and family--when all of a
sudden after biting into some really tangy Buffalo wings, you find the right side
of your face suddenly swells. It swells so large and is so noticeable that
even your perpetually drunken buddy Fred drops his half-eaten chili dog onto
the nice fine rug your wife just purchased and points frantically at your
face. Fred being Fred of course doesn’t
drop his can of beer, since you and your cadre value beer as the most precious
commodity known to mankind, coming a close second to gold. Your other buddy, who’s name completely
alludes you, accidentally steps on the dog and smears the chili and in his
shock and awe he spills some of his beer right onto his shirt.
Forcing your way through
your inebriated buddies, you run to the bathroom (christened the “Powder Room”
by your beloved wife) and find that indeed your face is the size of half a
pumpkin. You hear a scream. You hurriedly return to the festivities only
to find everyone has forgotten about your sad predicament as your poor wife is
on her hands and knees frantically wiping and scrubbing the chili-stained
carpet while uncharacteristically spewing forth a barrage of foul-letter words
intermixed with repetitions of your name in a frenzied scream. One of your pals nearly stomps on top of her
as he jumps for joy when a touchdown is scored.
She sees you and gives you the most horrid look you’ve ever seen on a
human face, while raising up her third finger (next to that precious wedding
ring), pointing it in your direction.
“Life’s unfair,” you cry
to yourself. Then you recall you had a
similar incident (that is, with the swelling in your face) not more than a few
months back. The swelling wasn’t exactly
the same, was rather more painful, but you’d forgotten about it since, as with
most things in life, time has a funny way of making you forget shocking, profound
and even life-altering lessons.
Back then you had a
swelling, but it was under your jaw. At
first it came and went, usually whenever you ate something tangy or sour. Then one day it progressively ballooned,
causing intense pain that brought you to your knees crying like a baby for
help.
“I’ll bring you to the
doctor,” she said, “If you stop crying like a baby,” and she dragged you by
your ear to the car.
Your doc treats you with
an antibiotic and a steroid to reduce the swelling, and also refers you to an
Ear Nose and Throat specialist (otolaryngologist) who discovered you had
blockage out of the salivary gland under your jaw, which happens to drain
through a tiny duct that opens under your tongue. The ENT guy found a stone lodged in the duct,
reducing saliva flow and thus the reason your gland hurt like the dickens when
you ate something that really stimulates saliva flow. He dons a bright light on his head directing
it into your mouth, and after probing the duct with these thin devices, he incises over the the duct to open it wider
and with a bit more poking and prodding while pushing on your gland to push
more saliva out, the stone finally finds its way out of the duct and into your
mouth, whereupon the doc immediately retrieves it and proudly shows it to you.
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| Stone in Wharton's Duct |
With an odd sense of
humor not uncommon amongst ENT folk, and not a few beads of sweat populating
his brow, he exclaimed proudly, “It’s a boy!”
He looks again in your mouth and while pressing on the gland in your
neck, you feel saliva pouring out and he retrieves another stone. Your ENT doc literally dances with joy with
the second stone—he compares this blessed event to the delivery of twins.
 |
| Salivary Stones |
You immediately feel
better and the pain and swelling of the gland greatly declines as lots of thick
saliva and foul-tasting pus pours forth from the gland through the free-flowing
duct. He gives you instructions to
massage the gland a few times a day, drink plenty of water to stay well
hydrated, eat sour candy or sour drinks or foods to stimulate saliva
production, all to allow the saliva to flow from the gland and prevent
recurrence of this problem. He
instructed you to do this regularly even if you had not problems.
Only you had forgotten
about the instructions. Isn’t beer
similar to water anyway, providing proper hydration?
You then have an immense
revelation. Your ENT doctor is right
here at your football party! In fact,
he’s the guy who stepped on the chili dog, triggering the ear-curdling scream
from your beloved spouse, prompting her announcement that she’s filing for
divorce if you don’t straighten your act.
The ENT doc firmly
massages your face amongst the collective shock of your other pals. Explaining he is happily married and not
getting fresh with you, he drags you back to that powder room and forces you to
drink water right from the faucet while he returns to your fridge and grabs
another beer. For some reason, the half
dozen friends you’ve invited are also crowded into the tiny powder room
watching as miraculously the swelling starts to resolve as you sense an odd
salty taste inside the right side of your mouth.
You’re once again a
happy camper and return back to the game, knowing later the day of reckoning
with the love of your life (i.e., your upset spouse) is soon to come.
The first incident with
the swelling below the jaw was the result of a phenomenon known as sialolithiasis,
a condition where stones form in the saliva.
There are three major
salivary glands on each side of your face and jaw, as the picture above
depicts. These are the parotid gland, submandibular gland and sublingual
gland. You also have numerous much
smaller glands called the minor salivary glands that are dispersed all
throughout your mouth, lips and throat, lying beneath the pink mucosa that
lines these structures. The sublingual
gland has several microscopic pores that drain into the floor of your mouth.
However, the parotid and
submandibular glands are larger and have only a single duct that drains each
gland. The parotid empties into the
mouth through Stensen’s Duct, located
opposite your upper second molar on the buccal mucosa (the smooth pink tissue
on the side of your mouth, deep to your cheek).
The submandibular gland drains via Wharton’s
Duct, a tiny opening located within small raised bumps of tissue on the
floor of your mouth, one on each side of your lingual frenulum—a band of tissue
or a subtle pale line that runs from the floor of mouth and continues on the
undersurface (ventral surface) of the tongue.
You may have heard the term ‘tongue-tied.” In this condition, the frenulum is a more
prominent tissue band that can restrict movement of the tongue. When this condition occurs in newborns, it
can cause feeding difficulties, in which case the frenulum is cut or incised by
your friendly ENT doc; another topic for another day.
With only one source of
drainage from either the parotid or submandibular gland, you can imagine any
blockage of flow can lead to big-time problems.
If flow is disrupted, saliva is trapped, builds up within the gland
causing it to swell up and increase in size, a condition known as sialoadenitis. This often is very painful. If the saliva continues to remain trapped,
the gland becomes more inflamed and bacteria then proliferate causing an
infection, leading to nasty stuff such as fevers, increased pain, and overall
feeling downright miserable. As the
inflammation and infection progress, pus develops, sometimes draining from the
duct it if there is some space around the obstruction to do so, but if not, the
infection can progress and spread outside of the gland into other parts of the
face and neck, sometimes forming an abscess.
Obviously, blockage of
saliva flow is undesirable. How does
this occur? With the second situation
with sudden onset swelling and subsequent resolution, a mucous plug likely
formed in the Stensen’s Duct, causing your parotid gland (located on the side
of your face) swell like a melon. Saliva
is comprised of mucous along with thinner, less viscous liquid knows as serous
fluid. However in cases of dehydration,
where you’re not drinking enough water (and eating a bunch of salty foods with
little water intake increases this risk), the mucous becomes more prevalent,
makes the saliva thicker, and if allowed to gather in the duct can form a
plug. This obstructs the duct and unless
the plug is forced by saliva dammed up behind it, inflammation and infection
can occur.
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| A super-large stone removed from Wharton's duct |
In the first situation,
a salivary stone formed on Wharton’s Duct, causing the submandibular gland to
swell. This too occurs in states of dehydration, leading to salivary stasis, where the saliva sits rather
than flows out of the duct. Since saliva
contains minerals such as calcium, if left to sit, calcium crystals can form,
gradually increasing in size as more calcium salts accumulate, forming a
stone. The stone gets larger and larger
and can partially or fully obstruct saliva flow from the duct.
Treatment mainly
involves removing the obstruction. With
a mucous plug, increasing saliva flow by drinking more water, massaging the
gland that’s involved and applying warm compresses to it can aid in increasing
flow and pushing the plug out. Sometimes
the doc can dilate the duct with small probes—this widens the diameter to
improve ductal outflow. Likewise with a
stone, these measures can aid in forcing saliva flow around the stone and, if
small enough, forces the stone out. With
larger stones however, other measures such as incising the duct and retrieving
the stone may be needed. If located too far from the ductal opening or if the stone is within the part of the duct that
is inside the gland, the salivary gland itself may need to be removed.
The best measures to
prevent this from recurring, is to drink plenty of fluids like water or
electrolyte drinks (and not beer, alcohol or caffeinated beverages, which can
lead to diuresis and increase your risk of dehydration). The full gamut includes:
1. Plenty of
fluids.
2. Massage
the gland three times a day or more, with firm pressure from front to back to
move saliva out of the gland.
3. Sour candy
(or sour sugarless candy if you are diabetic) 3-4 times a day, such as Lemon
Drops or Skittles.
4. Warm
compress the gland three times a day.
5. Anti-inflammatory
medication such as ibuprofen (ie, Motrin, Advil) or naproxen (ie, Aleve) as
needed for pain or discomfort.
Alternatively, you may take these daily for 1-2 weeks to alleviate any
inflammation within the gland. Don’t
take these if you have had problems with these in the past, or if you have
stomach ulcers or bleeding problems or are on blood thinners.
These measures often help to reduce or prevent the
recurrences of sialoadenitis and measures 1 through 4 should be done daily,
even when not having any symptoms whatsoever.
So there’s the lesson on
salivary duct problems and salivary stones.
The other vital lesson: whenever you invite your ENT doc to a party,
keep a headlight available and the beer plentiful.
©Randall S. Fong, M.D.
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