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Oral Surgery

Authors : Dr Atul Abhishek , Dr. Shishir Mohan , Dr. Arti.
 

ABSTRACT

Sialolithiasis is a disease that is characterized by the presence of sialolith in the different parts of the salivary gland. Sialoliths are hard structures of oval shape with different size. The color varies from white to brown and has a nodular surface. Sialoliths are usually composed of an intensely calcified organic core and is surrounded by an alternative layer of organic and inorganic substance. Sialoliths occurs with a frequency of 1.2%.

The most common site is the submandibular gland. We present a case with the chief complain of pain , swelling and extraoral pus discharge at the left submandibular region. Based on the radiographic and clinical examination a diagnosis of sialolithiasis of the left submandibular gland was made. The sialolith was removed under general anesthesia.
 

INTRODUCTION

Sialolithiasis is characterized by the development of salivary stones, known as salivary calculi or sialoliths in the salivary duct or in the salivary gland. More than 80% of salivary sialoliths occur in the submandibular gland, 6-15% in the parotid gland and around 2% occur in sublingual and minor salivary gland1,2. Frequency of occurrence is 1.2%, with male predominance.3 Salivary calculi develop due to deposition of mineral salts around a nidus of bacteria, desquamated cells or mucus. Sialoliths are composed of organic and inorganic substances.

The organic layer is composed of condensed mucus, mucopolysaccharides, glycoproteins, cellular elements and lipids while the inorganic material is composed of calcium phosphate, calcium carbonate, and trace elements. The etiology of sialolith is assumed to be related to the specific physiological and anatomic factors of the affected gland. Submandibular stones are made up of 82% of inorganic and 18% of organic material, whereas parotid stones are formed of 49% inorganic and 51% organic material3.
 

CASE REPORT

A 30 yr old male patient came to the Department of Oral and Maxillofacial Surgery, K.D Dental College, Mathura, for the assessment of swelling and pus discharge at the left submandibular region. The patient was unable to describe precisely how long the lesion had been present. Extraoral examination revealed a diffuse swelling at the left submandibular region.(Fig 1) On palpation, it was tender and hard in consistency.
 
Fig- 1( preoperatively) Fig- 2( CT Scan )


CT scanrevealed(Fig 2) multiple calcific foci seen in the left submandibular gland forming calcified mass measuring 3.3×2.8 cm in axial plane and 4.5cm in craniocaudal dimension. Adjacent fascia and muscles appears mildly edamatous. Small sinus formation seen with stranding of adjacent fat.A left submandibular incision was given, followed by blunt dissection to expose the calcified submandibular gland. The entire calcified gland was taken out ,and a drainage tube placed.
 
Fig-3(intraoperatively)Afterdrapping,
Betadine painting done
Fig-4(submandibular incision given) with
the BP blade no.15, 2cm below the left
Inferior border of mandible
 
Fig-5( dissection done) with the help of
Curved forceps till the megalith exposed.
Fig- 6(dissection and exposure done) of
the megalith.
 

DISCUSSION

Sialolithiasis is the main cause of obstructive salivary gland diseases, being involved in 66% of cases and accounting for about 50% of major salivary gland diseases4.Several factors contribute to the development of salivary stones in the submandibular gland. The saliva from the submandibular gland has a high content of mucin and flows uphill in a wider and longer duct as compared to the parotid gland. Stenson's duct (parotid gland) is narrower and the serous saliva from the parotid gland flows down hill. In addition, the saliva secreted by the submandibular gland is more alkaline and has a higher content of calcium and phosphate which promotes stone formation.4,5
 
Fig-7(harvested specimen) after exposure
Megalith removed
Fig- 8 ( suturing done ) after placing draining
tube.


Giant sialoliths are rare. Small sialoliths are well visualized on panoramic and periapical radiographic but can be obscured with superimposition over the roots of premolar and molar teeth hence, better visualized by an occlusal radiograph without overlap from other anatomy.6

Sialadenitis with or without sialolithiasis has been widely reported as the most common non-neoplastic pathologies of the submandibular salivary gland. 7,8 Although surgical excision of the salivary gland is a well-established treatment modality for sialolithiasis, new endoscopic/non-invasive techniques which allow the conservative removal of salivary calculi have been developed. 9,10These include lithotripsy, basket retrieval technique and balloon dilatation. With these techniques, over 70% of stones can now be retrieved leaving a functioning gland.11
 
Fig – 9 ( sutured with romobag )
 

CONCLUSION –

Giant sialoliths are accompanied by long-standing salivary gland sialadenitis resulting in a grossly fibrotic and poorly functioning gland.Submandibular gland removal is indicated only when there is a stone of substantial mass (12 mm or more) within the gland itself that is not surgically accessible intraorally and when there are small stones present in the vertical portion of Wharton's duct from the comma area to the hilum. Surgical removal of gland is also indicated in situation where opening of the duct surgically created recurrent infection of the gland due to ingress of oral fluids.
 

REFERENCES-

  1. Iro H, Schneider HT, Födra C, Waitz G, Nitsche N, Heinritz HH, et al. Shockwave lithotripsy of salivary duct stones. Lancet 1992;339:1333-6.
  2. Lustmann J, Regev E, Melamed Y. Sialolithiasis. A survey on 245 patients and a review of the literature. Int J Oral MaxillofacSurg 1990;19:135-8.
  3. Singhal I, Thomas H, Shah G et al. Surgical Removal of an Unusually Large Sialolith: A Case Report. International Journal of Advanced Health Sciences Vol 1 Issue 9 January 2015.
  4. Montes LC, Garcés-Ortíz M, Salcido-García J et al. Giant Sialolith, Case report and review of literature. J Oral MaxillofacSurg 2007; 65:128-30.
  5. Marchal F, Kurt AM, Dulgerov P et al. Retrograde theory in sialolithiasis formation. Arch Otolaryngol Head Neck Surg 2001 Jan;127: 66- 8.
  6. Lokeshbabu, Jain M. Giant submandibular sialoliths: A case report and review of literature.International journal of head and neck surgery, sept- dec 2011;2(3):154-157.
  7. Gott YH, Sethl DS. Submandibular gland excision: a five-year review. J LaryngolOtol 1998;112:269–73.
  8. Wenig HM. Atlas of Head and Neck Pathology. Philadelphia, PA:W.B. Saunders, 1993.
  9. Chu DW, Chow TL, Lim BH, Kwok SP. Endoscopic management of submandibular sialolithiasis. SurgEndosc 2003;17:876–9.
  10. McGurk M, Escudier MP, Brown JE. Modern management of salivary calculi. Br J Surg 2005;92:107–12.
More references are availabe on request.