In-Office Salivary Stone Removal

[Dr. Gopi Shah]
What about you mentioned, you're going to express the gland to see if you can get anything out of the duct and, sometimes you get saliva. Sometimes you don't. What about the patient? You feel a salivary stone and you get milky turbid-looking fluid or pus. Do you cool it down and then address it? Or do you address it that day? What are your thoughts on that when it's sort of maybe on the not quite infected unless there's maybe it is it's about to pus or, maybe it's kind of inflamed? The gland is hard, but you feel a stone.

[Dr. Ashley Agan]
I think that I wouldn't necessarily say that that's a contraindication to doing a sialolithotomy that day but when things are infected and there's more inflammation, you have to be prepared that there might be more bleeding and that it may not be, as clean and nice and easy as it is when it's cooled down. My preference would be to, send them home on some antibiotics and maybe cool things down, get some imaging in the meantime if they haven't had it, and then maybe come back, in a week or two and kind of schedule it that way, which typically, our billing team prefers for us to give them a week or two for preauthorization and things like that.

Sometimes that is kind of the perfect sequence of events to kind of like see, assess, have a plan, come back, and do the intervention. Sometimes patients have driven four or five hours to see me and it just doesn't make sense to send them home on antibiotics and make them drive all the way back for something that potentially could be taken care of that day. So again, it's one of those gray areas where we talk about it. Depending on if I think it's really going to be difficult, like if it's a little more posterior and, maybe they're having a lot of pain with it too and worse, there's a lot of pus coming out, like I might just say like, you know what, like let's just start with some antibiotics. Especially if it's their first time.

Sometimes that salivary stone has been there for a while and this is the first episode of sialolithiasis that they've ever had. Maybe just treat it, especially if they're like maybe older and more frail and maybe they're on, more than one blood thinner and it's going to be a little less straightforward, a little more challenging, a little more risky, these types of things. You might be able to say, “hey, let's treat this infection.” This is the acute thing that's happening right now. Maybe this stone has been there for a while and hasn't been causing you issues and let's see what happens. Maybe the stone will continue to cause you recurrent infections henceforth or maybe, you were a little dehydrated or you, who knows, like for whatever reason, you had an episode of a salivary gland infection and once we treat it, maybe that will be the end. It's hard to know. Again, depending on the patient, I think it's a reason you could argue either way.