Three Days Pain/Swelling Below Right Jaw

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It’s been another busy night, mostly flu patients but a few other scattered maladies and injuries to keep life interesting. The next case, for instance, doesn’t sound much like flu. The nurse has just put a 15-year-old boy in bed 10 with a complaint of fever and facial swelling. Variety is the spice of life. Off you go to check him out.

It’s been another busy night, mostly flu patients but a few other scattered maladies and injuries to keep life interesting. The next case, for instance, doesn’t sound much like flu. The nurse has just put a 15-year-old boy in bed 10 with a complaint of fever and facial swelling. Variety is the spice of life. Off you go to check him out.

He gives a history of three days of pain and swelling in the right lower face and under the jaw line on the right side. He’s had some fevers up to 101. The pain and swelling have been getting progressively worse. He denies toothache. He doesn’t recall any trauma or break in the skin in the region.

 


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His past medical history is unremarkable. He doesn’t take any routine medications, just ibuprofen for the pain in his lower face and jaw. He’s never had anything like this before. When you ask him if his pain and swelling have any association with mealtimes he gets quiet for a minute and then nods. In fact, the first time he noticed this was at dinner.
On to the exam. His vitals are unremarkable, he just took some ibuprofen and has no fever right now. Looking at him, he has swelling on his right side, primarily in the submandibular region. It’s slightly red, warm and very tender. You have him open his mouth. You start by inspecting the teeth, looking for a cavity or something but they look fine. Then he lifts his tongue and you hit pay dirt.

You find a small stone sitting in the opening to the duct of the right submaxillary gland (Wharton’s duct). You tentatively touch it with your tongue blade and it flicks right out. Behind it, you can see a little pus oozing out of the duct. The patient already says he is beginning to feel better. On gentle palpation, you don’t feel any other stones.

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The stone (left) was easily removed, leaving behind an enflamed opening to Wharton’s duct (above). The stones are due to calcium and phosphate crystals that typically accumulate when the water content of the saliva is low.

So what’s with the rock in Wharton’s duct? Patients can develop salivary duct stones at any age, although most occur in adults. The condition is known as sialolithiasis. Wharton’s duct, which drains the submaxillary gland, is the most common site for stones. About 15% of stones form elsewhere, about 10% in Stenson’s duct (which drains the parotid gland in the cheek) and 5% in the sublingual ducts. The stones are due to calcium and phosphate crystals that are most likely to accumulate when the water content of the saliva is low, such as in dehydration or with medications that dry out your spit, such as antidepressants, antihistamines or diuretics.

Patients with stones will experience pain and swelling in the affected gland. This will worsen at mealtimes or if the patient eats something acidic that stimulates salivary flow, such as a pickle. The saliva may feel gritty or have a funky taste. Sometimes these symptoms last a few hours and subside. If the duct is blocked by the stone, infection of the gland can occur. The gland may become swollen, tender, or red and the patient may develop fever.


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Frequently, the diagnosis can be made by the history and exam, as in this patient. Sometimes, if a stone is suspected but not visualized, imaging may be helpful. A dental film that is shot at a right angle to the floor of the mouth may pick up a stone in Wharton’s duct. Alternatively, ultrasound or CT may be helpful. It is useful to keep in mind that 25% of stones are multiple.

If you see a stone, try to remove it, or gently milk the duct to see if it can be expressed. If not, an ENT referral is warranted. After the stone is out, review the patient’s medications to see if they are taking anything that dries out the saliva. Have them increase the amount of water they drink. Ask the patient to suck on sour candy or vitamin C tablets, which will stimulate salivary flow in the ducts. If the gland is infected, start them on a course of antibiotics such as cefalexin or dicloxacillin.

Remember, if you don’t think of it, you can’t diagnose it. When there is swelling of the salivary glands, go check out the ducts. Happy duct hunting.

Amy Levine, MD, is an associate professor of pediatric EM at UNC Chapel Hill 
 
Other causes of swelling of the salivary glands:

MUMPS – Usually affect parotid glands. Fever & other symptoms occur prior to gland swelling.
AIDS, Sjogren’s syndrome, sarcoidosis, diabetes mellitus – Should have other findings besides salivary gland swelling.
Cancer of the gland – Swelling usually firmer than that caused by infection.
Accidental biting injury – May harm a salivary gland and prevent the flow of saliva. The affected gland may swell and form a bluish, small, soft lump known as a mucocele.

6 Comments

  1. Great Find! I had this exact issue,. *I* (non-medical person) knew exactly what was happening. Walked right in to about 10 different doctors and said “I have a salivary stone”. They poked and prodded, found nothing. I could feel it with my tongue and push it back into the duct, sort of milk the gland empty and everything would be okay until it lodged at the exit of the duct again. which was often.

    First surgical procedure: I think the guy knocked me out and went to lunch.

    Second surgical procedure: He found nothing either. But, he did take the time to shove some large probes down in there and did a little trim on the duct exit. ( I love this guy!)

    3 days after the operation, the same old swelling and pain of the duct. Did my regular poke of the tongue trick and Ta-dah!!!

    Two fairly large stones popped out!!!! And some other unsavory issue.

    Took them on tour to most of the previous doctors ( some were a few 100 miles away) and gave them The Look.

    Haven’t had a problem since.

    Please keep spreading the word!

    • It’s 3:45 a.m…Wow amazing story. My mom has been experiencing symptoms of facial swelling.. Her experience has been ongoing, on and off for about last 2 yrs! My poor mommy. Unfortunate, for my mom that she had to suffer for so long yet I feel fortunate, that I’ve stumbled across this post.. My siblings and I have taken turns taking her to numerous doctor visits, and a specialist, getting same results but no diagnosis…sooo frustrating!..each time. They each tell us to have her try to suck on hard candy, rinse with biotene, try new toothpaste, drink more water, allergies, get her teeth check and even had some bad ones pulled. So next Wednesday in fact, I’m taking her to yet another Dr’s visit and will be asking for a CT scan and also check for the possibility that it may be a blockage due to salivary stones! I have no doubt that this may be the culprit. It’s just very frustrating to feel like I needed to resort to the internet to try to help find/research a diagnosis for my mom’s condition…especially when the Drs we’ve take her to have prestigious degrees..and internet access as well, to help their patients…and we’re paying them!!! Boggles one’s mind! BIG SIGH.
      P.S. will try to update after her Dr’s appt on Wednesday. Wish us luck!

  2. Hooray,thanks to your post’s I now know what’s been going on with my mouth and cheek.I developed all the symptoms mentioned booked a doctor’s appointment and he diagnosed the problem,its been two weeks and no sign of it getting better so back to the doctors I go.cheers.

  3. I would love to see images of this. I was at the dentist yesterday, had a full image done of my jaw and he referred me to an oral surgeon. I feel a lump under my jaw on my right side, I’ve been complaining of headaches, right side lower jaw pain, slight swelling visible on my right cheek. I’ve had this issue before and had work done on some of my teeth. I pray that this is the issue and not cancer. They mentioned extracting 5 teeth. CT scan on Monday.

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