SAEM Clinical Images Series: There’s a Stone Under My Tongue


A 44-year-old female presented to the emergency department with the complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for two 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.

Vitals: BP 156/92; Pulse 80; Temp 98.4°F; Resp 14; SpO2 100%

General: Sitting on chair, no acute distress

HEENT: Localized swelling to the inferior lingual frenulum at Wharton’s duct with associated erythema. Partially visualized white calculus, palpable through the mucosal membrane.

Sialolith in Wharton’s Duct. There was visual and tactile evidence of a calculus under the patient’s tongue. It had slowly grown and was associated with increased pain and swelling while brushing her teeth.

The majority of sialoliths can be managed conservatively with hydration, moist heat application, massaging of the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may benefit from excision in the emergency department. In the case above, local anesthetic was injected, and manual expulsion was attempted but was unsuccessful. The emergency physician made a single 1 cm incision over the calculus and a 0.5 cm x 0.75 cm sialolith was removed with minimal bleeding. The patient was discharged on a course of amoxicillin-clavulanic acid.

Take-Home Points

  • Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80-90% arising from the submandibular glands. 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.
  • Conservative treatment is the mainstay of sialolith management. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.
  • Huoh KC, Eisele DW. Etiologic factors in sialolithiasis. Otolaryngol Head Neck Surg. 2011 Dec;145(6):935-9. doi: 10.1177/0194599811415489. Epub 2011 Jul 13. PMID: 21753035.