Sucking on lemons is not a common past time but once you realize you have a stone in your salivary gland (a sialolith), it's a must. We just have had the experience of it recently in the family when my husband started feeling sick. The area under his left chin started swelling. It wasn't painful and so we dismissed it as a swollen lymph node since we had a friend over with a flu a few days prior to the swelling. Two days went by and the swelling increased, it started to look like mumps, and he said it was quite painful when he eats and his tongue moves. We still didn't pay much attention. The next morning though, he inspected the area under his tongue and realized it was also quite swollen and looked a but strange. It was a weekend and in Germany, the only option is to go to the weekend practice at the hospital.
We explained the situation to the doctor and she started examining him. She asked him to open his mouth and put his tongue up. She then wore gloves and started touching the swollen area when pus started coming out. 'It's a stone,' she said 'but I'll refer you to an emergency Ears, Nose and Throat (ENT) specialist in another hospital to be sure'. Stone under the tongue? We haven't heard of such a thing. It is apparently quite rare and affects only about 1% of the population. No wonder we haven't heard of it! The beauty of the internet is that it is easy to find information through googling. And that's what we did. Thankfully, we have some friends who are physicians, one who is an ENT, and so we could get enough guidance. We went to an ENT on the same day and she confirmed it was a stone and she prescribed my husband to take some antibiotics since the area around it was infected, hence the swelling.
Our ENT friend told him to massage the area under his left chin, drink lots of water and suck on lemons, which can help move the stone. Massaging the area stimulates the gland to produce more saliva and drinking water increases the amount of fluids while the sour taste of lemons make saliva rush into into the mouth. This creates a sort of a 'flood' that can hopefully push the stone out. On top of these, I have read that to decrease the infection, he has to gargle with chamomile and sage tea and so he would do this several times a day, keeping the tea in his mouth for a few minutes before spitting it out. A few days after taking antibiotics, the swelling was much less and our friend instructed him to try and push the stone out with his finger. Only pus came out but he did all of what was instructed. We went for a check-up a week after the first diagnosis and the ENT at the hospital recommended surgery. He checked the stone with an ultrasound but couldn't exactly tell how big the stone was but concluded that it was too big for a sialendoscopic surgery.
Sialendoscopy involves the insertion of a small tube into the salivary canal to take out the stone. It is the least invasive way of dealing with sialoliths but unfortunately, it works only for stones up to 4mm in diameter and the doctors said his was more than that based on feeling the stone with their fingers. There are cases where, if the stone is slightly bigger, they would use sialendoscopic laser to break the stone and then take it out after several sessions but it is time consuming and of course hospitals earn money by the minute. I'm not quite sure if the health insurance pays much for sialolith extraction and of course it becomes less attractive financially for doctors and hospitals in general when they can earn more from other types of surgery. So, the ENT at the hospital recommended an invasive surgery requiring an incision on the salivary canal that is big enough for them to get the stone out. It was only quite disturbing when they said that they are going to leave the cut open and stitch the tube to the area next to it instead. Of course, such a procedure is not without risks and as they informed us of a potential damage to the lingual nerve, we became even more worried. Online, there have been cases where the nerve has been partially damaged and patients couldn't feel their lower lips for years!
In any case, despite all the worry, he was still lucky that the stone was just about 1cm from the opening of the salivary canal and that it was under the tongue in the submandibular gland. Had it been in other areas, such as above the jaw, in the parotid gland, things would be much more complicated as the glad is close to many facial nerves. Salivary stones, however, although painful and can cause infections, are not necessarily life threatening.
How do they form? Based on the information available, there are several factors influencing the process although there is not one exact cause. First, genes play a role. The more genetic predisposition you have of forming stones, the higher the risk of forming salivary stones as well as kidney stones. Second, drinking insufficient amounts of fluids slow down salivary production causing sediments to build up in the saliva. Third, eating foods with high oxalate contents and not balancing it out with foods with high calcium content.
The healthiest foods we know such as spinach has high amounts of oxalic acid, which contributes to the formation of stones in general. If it gets absorbed by the body, it binds with calcium in the saliva or the kidneys, producing microscopic crystals that grow in size over time if left in the glands (or kidneys). This can be prevented if high oxalate foods are consumed with calcium-rich foods since the oxalic acid binds directly with calcium during the digestion process and the crystal is passed out of the body through defecation. A good example of this harmonious duo is a Korean spinach side-dish called Sigeumchi-namul, where spinach (high oxalate) is mixed with sesame seeds (calcium-rich).
How about areas with hard water, does it affect stone formation? The answer is perhaps, but it depends on your diet. In contrast to popular belief that hard water increases the formation of stones, this is most likely not the case. Since hard water contains more calcium, it actually is supposed to prevent the formation of stones if your diet has high oxalate content. Less is known, though, about whether drinking hard water increases the risk of stone formation if diet has low oxalate content.
So what happened to my husband in the end? Well, we set an appointment for an invasive operation, which was a week after the check-up. While waiting for the operation, he continued his routine. He drank a lot of water (about 2 liters a day), he massaged the gland under his left chin by pressing it hard with a forward stroke from above the neck to his chin, he sucked on sour lemons several times a day, gargled with chamomile or sage tea and he tried to push the stone with his finger placed under his mouth stroking it from the back to the front. Pus usually came out, draining the tube, but after a few days, some blood started coming out. We thought it was the infection getting worse but then the swelling was not much bigger and so we assumed that perhaps the stone has moved, causing some stretching to the tube, which made it bleed. We were happy at the thought since it meant that the incision for the surgery would be a few millimeters less.
At 2am last night, my husband suddenly got up complaining of pain under his tongue. He started massaging his gland, gargled a bit and used his finger to push some pus out. Some blood came out though and the area near the opening of the tube was black. We were worried but agreed that perhaps it is the stone coming out. He went on pushing the pus and blood out when suddenly, the stone popped out! There was a small hole a few millimeters from the opening of the tube, where the black spot used to be. The wound bled a bit but stopped after 10 minutes. He gargled again with chamomile tea and then went to bed.
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One thing is for sure in this experience, he will be eating more sour foods now from time to time, drink a lot more water and balance his high oxalate diet with calcium-rich foods to prevent any stones from forming in the body.
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