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Surgical
removal of a large submandibular salivary stone
Case report
Dr. faaiz Y. Alhamdani;
B.D.S, M.Sc*
Dr. Ahmed F. Alhadithi; B.D.S.**
Abstract
A twenty-six years male, presented to the oral
surgery clinic, complaining from recurrent submandibular
swelling in the left side, due to submandibular stone in the
left Wharton's duct. The size of the stone is relatively large.
In this case report, we will discuss the possible cause for such
large size of the stone and the technique of surgical removal.
Key words: surgical removal, submandibular, large
salivary stone.
Introduction
The formation of stones, or calculi, may occur throughout the
body, including the gallbladder, urinary tract, and salivary
glands (1). Salivary stone occasionally forms in a salivary
gland or duct, usually by deposition of calcium salts around a
nidus of organic material, and has a layered microscopic
structure (2) Salivary gland stones are the most common disease
of salivary glands. It is estimated that it affects 12 in 1000
of the adult population.(3) Males are affected twice as much as
females(4) Children are rarely affected but a review of the
literature reveals 100 cases of submandibular calculi in
children aged 3 weeks to 15 years old.(5) The peak incidence of
salivary gland stones is between ages 30 and 50(1). Large
sialoliths have rarely been reported in the salivary ducts (6).
Salivary gland stones (calculi) are the commonest intraluminal
cause of recurrent salivary gland swelling. Submandibular
calculi are the most common (4) Submandibular sialolithiasis is
more common as its saliva is (i) more alkaline, (ii) has an
increased concentration of calcium and phosphate, and (iii) has
a higher mucous content than saliva of the parotid and
sublingual glands.(4), (7) In addition, the submandibular duct
is longer and the gland has an antigravity flow.(4).
Almost half of the submandibular calculi lie in the distal third
of the duct and are amenable to simple surgical release through
an incision in the floor of the mouth, which is relatively
simple to perform and not usually associated with
complications.(8)
Although surgical removal of submandibular stone still popular,
recently; both minimally invasive, and conservative approaches
for the diagnosis and treatment of salivary gland stones, were
introduced, such as sialoendoscopy and extracorporeal shock wave
lithotripsy (ECSWL).
These techniques proved to be successful in the treatment of
small salivary gland (less than 3 mm) (1).
Case history
A twenty-six years male referred to oral surgery department
in Alkarama specialized dentistry center, complaining from
recurrent submandibular swelling in the left side of 10 years
duration with duration between episodes about 1-2 years
duration. The patient used to deal with the condition by
antibiotics and some times with the aid of submandibular massage
with discharge of saliva and pus which give him relief for
several months.
Few days ago he recalled his dentist who suspected the presence
of a stone in the submandibular duct as he notices a swelling
along the course of the left sub mandibular gland. Occlusal
radiograph was taken; it shows an egg shaped radiopaque mass,
which confirmed the diagnosis.
Surgical procedure
After taking the patient medical history, a thorough clinical
examination was done to assess the exact position of the stone
to see the possibility to remove the stone under local
anesthesia
A preoperative prophylactic dose of Lincocine 600-mg was
administered I.M., 30 min. before incision making. Lingual
anesthesia was given afterward.
The tongue was retracted by a piece of gauze. The duct sutured
loosely behind the stone to prevent its posterior dislodgment,
about 3-cm mucosal incision was performed against the stone
position in the longitudinal axis of the duct. Upon dissection
to reach the stone sublingual salivary gland structure
encountered, it was a little bit difficult to expose the stone
after incising the duct lining because the fibrous adhesions
resulting from recurrent inflammatory processes.
After its exposure, we grasped the stone gently by mosquito
artery forceps, and the adhesions were relieved by excavator end
of the surgical cumine, which facilitate its removal. The size
of the stone was 2 by 1cm.
Copious irrigation and suction was done to ensure removal of
possible minor stones posterior to the removed stone, and a
clear mucous secretion was noticed through the wound incision.
After ensuring haemostasis, Closure of mucosal wound was done
with 3/0 silk suture. Postoperative analgesic and antiseptic
mouthwash were prescribed
Discussion
It's not known why some submandibular stone reach to a
considerably large size before the patients seek the treatment,
and the available data doesn't give us a clue (6). In this case
we believe that continuous milking procedures and over a long
period of time, has delayed the incidence of total duct
obstruction which allow the saliva to bypass the gradually
enlarging stone before total duct obstruction. Recurrent
swellings which has been managed by the patient by milking of
the duct, reflects that there was a recurrent attempts for
formation of stone in the duct, but in this case, his measures
to milk the stone failed. Recurrent inflammatory process of the
duct, imposed it self as technical difficulty in surgical
manipulation. Long incision (more than the estimated length of
the stone) will provide adequate accessibility and insure more
control. Removal of long standing salivary gland stone requires
a delicate and careful handling to avoid unnecessary damage to
the duct and adjacent structures. Ensuring hemostasis before
suturing is of crucial importance, as it prevents postoperative
haematoma.
Conclusion:
Although new conservative technique where introduced recently
for the treatment of submandibular stones, no data available
supports its effectiveness in the treatment of large salivary
gland stones, in fact large size stones has resulted in
technical failures in some cases treated with extracorporeal
shock wave lithotripsy (9).
Intra-oral surgical approach for removal of large submandibular
stone is still effective, safe, and can minimize the incidence
of further submandibular stone formation through the duct
revision (1).
* Assistant lecturer. Oral surgery department/ college of
dentistry, Almustansiria University.
** Periodontology department /college of dentistry-University of
Baghdad.
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