Intraoral Approach for Removal of Large Sialolith in Submandibular Gland

Abstract

Sialolithiasis is a benign pathology that occurs most frequently in the submandibular salivary gland due to its anatomic features. Depending on the size and degree of calcification, a sialolith can be visible in radiographic examinations. Patients commonly experience pain and/or edema when the ducts are obstructed. The authors report two cases of sialolithiasis of the submandibular gland after searching for the source of swelling in the submandibular region. The diagnosis was confirmed by clinical and tomographic examinations. Despite the considerable size of the sialoliths, treatment consisted of the removal of the calcified mass using an intraoral surgical approach. The prognosis is often good and there is generally no recurrence of the condition.

Transcervical Removal of a Rare Giant Proximal Wharton’s Duct Sialolith and Submandibular Gland

“…[22] Statistically, almost half of the submandibular sialoliths situated in the distal third of the duct and are amenable to simple surgical release through an incision in the anterior floor of the mouth directly onto the calculi. [5,17,21,23] However, sialolithotomy within the proximal duct in the so-called comma area is difficult, demanding, and may be detrimental to the lingual nerve and can be more problematic if it is a giant sialolith. Nonetheless, extended incision of the duct has been constantly preferred as a gland preserving management.…”

“…[24] Therefore, the ability to palpate the calculus, irrespective of its position or dimension, is considered to be the most important aspect in the successful trans-oral removal of the stone. [23,27] Foletti, et al (2017) developed an algorithm for choosing the best minimally invasive technique for managing submandibular and parotid sialoliths, according to the size of the calculi, and their position in the excretory duct for which may be applied in smaller size calculi, not more than 10 mm of diameter. [12] Other alternative treatment for sialolithiasis includes extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal shock wave lithotripsy (ISWL).…”

“…Among the case reports were from Soares, et al [3,20,29,[30][31][32][33] However, there was one case reported of an intraoral removal of giant sialolith (25 mm) located at the proximal part of Wharton's duct but it was not mentioned whether it was extending into the intra-glandular ductal at the hilum and causing obstruction as in our case. [23] A study by Park, et al (2012) to identify a surgical landmark for a suitable approach to remove proximal Wharton's duct and hilum sialoliths, found that all of 74 patients had successfully underwent intraoral removal of the sialoliths with a mean size of 8 mm, which was below the size of giant sialolith. [26] In our case, an unusual large stone at proximal part of Wharton's duct which extended into intra-glandular duct at the hilum was not removable intra-orally because of a high degree of difficulty, the calculus was not palpable intra-orally, the risk of injury to adjacent important structure, and the fact that the gland which has already been damaged, was obstructed and non-functional.…”

A megalith (giant sialolith) in Wharton’s duct

“…The constituent minerals are various forms of calcium phosphate, like hydroxyl apatite octacalcium phosphate. Calcium and phosphorous ions are deposited on the organic nidus, which may be desquamated epithelial cells, bacteria, foreign particles, or products of bacterial deposition [3,7,9]. Submandibular stones are composed of 82% inorganic and 18% organic material, whereas parotid stones are composed of 49% inorganic and 51% organic material [3,7,8,10].…”

Submandibular Megalith: Case Report

“…4 Diagnosis is generally performed with the aid of panoramic and occlusal radiographs, but tomography, sialography, ultrasound, scintillography, and sialoendoscopy can also be used. 3 This case report is deal with a submandibular megalith, its characteristics and surgical approach.…”