Woman with a lump under her tongue.

Abstract

A 44-year-old woman presented to the emergency department with a complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for 2 years. The day prior she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain. Physical exam revealed erythema and swelling localized to the inferior lingual frenulum at the Wharton's duct. A white calculus was partially visualized and palpable through the mucosal membrane (Figure 1). Otolaryngology was telephonically consulted and recommended infiltrating with local anesthetic and attempting manual expulsion or excising, if needed. Manual expulsion was unsuccessful; a single, 1-cm incision was made over the calculus, and a 0.5 cm × 0.75 cm sialolith was removed with minimal bleeding (Figure 2). The patient was discharged on a course of amoxicillin–clavulanic acid. Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80% to 90% arising from the submandibular glands.1 As with our patient, the most common presentation is a single calculus within Wharton's duct causing pain and swelling during periods of increased salivation (ie, brushing teeth, preparing to eat).2 The majority of sialoliths can be managed conservatively with hydrating, applying moist heat, massaging the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.3