Detection of sialolithiasis by point-of-care ultrasound at ED

Abstract

Case A 38-year-old man with no significant medical history presented to the emergency department(ED) with progressive right cheek swelling and tenderness. Odynophagia and difficulty in opening mouth fully was mentioned. He denied fever, trauma, and dyspnea. The vital signs at triage were within normal limit. Swelling over right submandibular area with tenderness and mild warmth while palpation was noticed. Mouth opening was limited to two fingers width. Point-of-care of Ultrasound(PoCUS) was performed at ED and a hyperechoic lesion in the Wharton duct with ductal dilatation was revealed. The sonographic findings were compatible with sialolithiasis. The patient was discharged with medications for symptoms relief and was instructed to visit an Otorhinolaryngology OPD for follow up. Discussion The incidence of Sialolithiasis is reported about 1% in previous studies.1,2 Most (80 to 90 percent) salivary gland stones occur in the submandibular glands. Submandibular stones tend to be larger than stones in other glands and are most often located in the duct.1,3 Patients typically present with pain and swelling on the affected side and those symptoms are usually exacerbated by eating. Computed Tomography has traditionally been the diagnostic tool to identify undifferentiated jaw swelling, with high sensitivity at identifying sialolithiasis(sensitivity of 98 % and a specificity of 88%).4 Recently, ultrasound has become the first-line diagnostic tool for the salivary gland stones, especially stones 2 mm in diameter or larger, with the sensitivity more than 90 percent reported5,6 In our case, the POCUS study provided valuable information for diagnosis and expedited the disposition. CT or other imaging techniques could be reserved for those with inconclusive sonographic findings or those with complicated conditions(such as tumors or abscesses).