1. By Erik Paulson, D.O.

2. History CC- 15 y.o. male c/o pain and swelling in jaw. 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. Began yesterday, thought it might be strep throat or something so he began taking left over Amoxicillin from last year. NKDA NKDA Seasonal allergies relieved by Claritin and Benadryl. Seasonal allergies relieved by Claritin and Benadryl. No other meds No other meds Vaccinations up to date Vaccinations up to date

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

4. Differential Diagnosis Infection Infection –Lymphadenitis Mono Mono Strep Strep –Sialadenitis Mumps- vaccinations are up to date Mumps- vaccinations are up to date Stone Stone Sjogren’s Sjogren’s –Abscess Neoplastic Neoplastic

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

7. Diagnosis Sialolithiasis with secondary sialadenitis Sialolithiasis with secondary sialadenitis

9. Quiz time Duct from Parotid gland is called? Duct from Parotid gland is called? –Stensen’s duct Duct from Submandibular gland is called? Duct from Submandibular gland is called? –Wharton’s duct

10. Pathophysiology Dehydration Dehydration –Concentration of saliva Fasting or Anorexia Fasting or Anorexia –Stasis of saliva Drugs- Anti-histamines, Anti-cholinergics. Drugs- Anti-histamines, Anti-cholinergics. –Decrease production of saliva Stone can cause stasis of saliva and subsequent bacterial ascent into the gland. Stone can cause stasis of saliva and subsequent bacterial ascent into the gland. –Infection most commonly from S. aureus or Strep Viridans.

11. Fun Facts about Sialolithiasis Twice as common in males Twice as common in males 1% incidence at autopsy 1% incidence at autopsy Stones are usually made of calcium phosphate Stones are usually made of calcium phosphate

12. Treatment Conservative 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 Surgical –Wire basket retrieval under fluoroscopy. –Duct cannulation –Gland removal for recurrent cases Lithotripsy Lithotripsy

13. 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. 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. Lymphatic pumps to improve immune function. Increase/ normalize parasympathetic tone, decrease/ normalize sympathetic tone. Increase/ normalize parasympathetic tone, decrease/ normalize sympathetic tone.

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

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