A 58-year-old male presents with rapidly increasing pain and tenderness on the right side of his face, centering near the right temporomandibular joint and extending down his neck. He denies trauma but feels achy all over. He had just tried to use a cough drop, and this caused a sudden, intense burst of pain.

The man’s vital signs indicated a low-grade temperature of 99.8° F. His pain rating was an 8 at rest. The right side of his face was visibly swollen. The area was warm and exquisitely painful to touch, and submandibular and anterior cervical lymph nodes were enlarged. An oral exam showed a swelling near the posterior gum line that was very tender. With the history of increased sharp pain with a cough drop, a preliminary diagnosis of sialolithiasis, or salivary duct stone, was made. These stones are formed by crystallization of certain chemicals in normal saliva but occur often in cases of dehydration or use of medications that cause dry mouth. Often, these stones are so small that they pass on their own. When they are large enough to block the duct, the back-up of saliva becomes inflamed, and often a localized infection ensues. Intervention begins with increasing fluid intake and sucking on sour candies or other foods to intentionally increase the flow of saliva in an attempt to “float” out the stone. Application of heat often helps. Another simple technique is to massage the area in a “milking” fashion, applying pressure in the direction of salivary flow to try and force the stone free. In a small percentage of patients, actual surgical intervention is needed, either by making a small slit at the duct or using new micro-endoscopic techniques to snare the stone. Antibiotics are given for the infection.

This patient was not improving after 36 hours and sought relief from his ENT physician, who performed the massage technique with immediate release of a “gush” of foul-tasting saliva. His pain improved rapidly from that point, and he recovered without further incident. (211-7)

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Sherril Sego, FNP-C, DNP, is an independent consultant in Kansas City, Mo. 

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