A 40-year-old woman presents to the clinic for intermittent pain in her jaw. She has been having intermittent discomfort on the left side of her face for the last 1-2 months with frequent episodes of having a dry mouth. She has also noticed episodic swelling of her left lower jaw, as well as discomfort when opening her mouth at times. She has noted a painful area under her tongue especially when she is hungry and when she eats. Her medical history includes hypertension for which she takes hydrochlorothiazide. Her social history is significant for a 8 pack-year smoking history and drinking caffeine consistently throughout the day, usually in the form of coffee and diet sodas. Vital signs are normal, and physical examination are within normal limits, including no cervical lymphadenopathy.
Which of the following is the most likely diagnosis?
- A) Cluster headache
- B) Retropharyngeal abscess
- C) Sialolithiasis
- D) Sinusitis
- E) Trigeminal neuralgia
The patient most likely has sialolithiasis, which is defined as a calculus in the salivary glands or duct. Signs and symptoms are variable and depend largely upon whether the obstruction of the duct is complete or partial and how much resultant pressure is created within the gland. The development of infection in the gland also influences the signs and symptoms. Sialolithiasis can present with a gritty feeling under the tongue or jaw and/or pain in those areas. Sometimes, as the stone moves, it can cause the patient to have a twitch in the eye on the affected side. Stones will form in the salivary gland or ducts following the stagnation of saliva; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium
Common risk factors associated with sialolithiasis are hypovolemia, diuretics, anticholinergic medications, gout, trauma, smoking, caffeine use, and a history of nephrolithiasis.
The classic treatment of sialolithiasis is antibiotics and anti-inflammatory agents, hoping for a spontaneous stone expression through the papilla. In cases of submandibular stones located close to Wharton papillae, a marsupialization (sialodochoplasty) is performed, and the stone removed. Salivary stones do not usually recur, but if they do, the salivary gland may need to be removed.
Answer choice A: Cluster headache, is incorrect. Cluster headache presents with bouts of frequent attacks, known as cluster periods, that last from weeks to months, usually followed by long periods of relief (remission). Cluster periods present with sharp extremely painful headaches in addition to eye findings such as drooping of the upper eyelid, watery eyes, or runny nose.
Answer choice B: Retropharyngeal abscess, is incorrect. It is unlikely for the patient to have retropharyngeal abscess as she has no fever, has intermittent symptoms, has no lymphadenopathy, and is non-toxic appearing.
Answer choice D: Sinusitis, is incorrect. Sinusitis usually includes chronic headache and pain in the sinuses.
Answer choice E: Trigeminal neuralgia, is incorrect. Trigeminal neuralgia can range from mild to severe shooting facial pain, triggered by chewing, speaking, or even touching the face. It can also cause facial spasms but usually does not present as a localized painful area underneath the tongue induced by hunger which is more indicative of sialolithiasis.
Key Learning Point
Sialolithiasis is a calculus in the salivary glands or duct, which can present with an intermittent discomfort in the jaw, pain with hunger and eating, as well as a gritty sensation under the tongue.
Dr. Raj Dasgupta