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Differential Diagnosis and Diagnosis of Sialolithiasis Treatment Of k Sialolithiasis 121 BILATERAL SIALOLITHS gland stones, and are intimately associated with the mandible. Phleboliths are commonly multiple Simultaneous sialolithiasis of more than one sali- in number and also exist within the neck outside of varyglandislesscommonthanmultiplesialoliths the submandibular triangle. They are scattered and and is estimated to occur in fewer than 3% of have a classic lamellated appearance with a lucent cases of sialolithiasis (Sunder, et al. 2014). This core. Finally, phleboliths are smaller than sialoliths notwithstanding, surgeons must be vigilant in and demonstrate an oval shape, compared to the terms of investigating for the possibility of multiple sialolith whose elliptical shape has been created gland involvement when preparing a patient for by a salivary duct (Mandel and Surattanont 2004). surgery related to a diagnosis of sialolithiasis. A One further entity worthy of mention is calcified review of the literature indicates that when multi- atheromas of the carotid artery which is sufficiently ple sialoliths occur, they occur in a bilateral same distant from the submandibular triangle so as to gland fashion rather than involving two different not be confused with a submandibular sialolith. salivary glands. These are most commonly located inferior and posterior to the mandibular angle adjacent to the intervertebral space between cervical vertebrae 3 Differential Diagnosis and and 4 (Friedlander and Freymiller 2003). Diagnosis of Sialolithiasis While the diagnosis of sialolithiasis is fre- quently confirmed radiographically, it is important Patients with sialolithiasis most commonly present for the clinician to not obtain radiographs prior to with clinical and historical evidence of salivary performing a physical examination. Bimanual pal- calculi. A history of submandibular swelling, pation of the floor of mouth may reveal evidence prandial pain, and bouts of sialadenitis are highly of a stone in a large number of patients. Similar suggestive of a diagnosis of sialolithiasis. This palpation of the gland may also permit detection notwithstanding, many patients are asymptomatic of a stone as well as the degree of fibrosis present k such that only a panoramic radiograph may allow within the gland. Examining the opening of the k for the diagnosis of submandibular sialolithi- Wharton duct for the flow of saliva or pus is an asis as it may reveal calcifications within the important aspect of the evaluation. It has been submandibular triangle. It has been observed estimated that approximately one quarter of symp- that submandibular stones located anteriorly are tomatic submandibular glands that harbor stones more often symptomatic than those lodged in the are non-functional or hypofunctional. Radiographs intraglandular portion of the duct (Karas 1998). should be obtained, and may reveal the pres- While such calcifications may lead to a diagnosis of ence of a stone. It has been reported that 80% submandibular sialolithiasis, it is important for the of submandibular stones are radio-opaque, 40% clinician to consider other diagnoses that present of parotid stones are radio-opaque, and 20% of with submandibular calcifications, particularly sublingual gland stones are radio-opaque (Miloro when pain is absent. Amongst these are calcified 1998). lymph nodes associated with mycobacterial adeni- tis (scrofula) (Figure 5.7), phleboliths associated with oral/facial hemangiomas (Figure 5.8), and a Treatment of Sialolithiasis mandibular osteoma as might occur in Gardner syndrome (Figure 5.9). All of these calcifications General principles of management of patients with may, at first glance, appear similar to submandibu- sialolithiasis include conservative measures such as lar sialolithiasis. Close examination of panoramic effective hydration, the use of heat, gland massage, radiographs may, however, allow for the clinician and sialogogues that might result in flushing a small to establish a radiographic diagnosis other than stone out of the duct. A course of oral antibiotics submandibular sialolithiasis (Mandel 2006). Most may also be beneficial. These measures may be par- submandibular calculi contain smooth borders ticularly appropriate since some patients may carry when they exist within the gland. Calcified lymph a clinical diagnosis of sialadenitis in case of a radi- nodes generally show irregular borders, and osteo- olucent sialolith. As such, the treatment is the same mas of the mandible are larger than most salivary in the initial management of both diagnoses. k k 122 Chapter 5 (a) (b) k k (c) (d) (e) Figure 5.7. A close-up of a panoramic radiograph obtained in a patient with a chief complaint of right submandibular pain (a). The calcifications noted on this radiograph are located in the retromandibular region as well as the submandibular gland area. Exploration of the neck showed indurated lymph nodes present in association with the right submandibular gland, but clearly not sialoliths (b). The lymph nodes were removed (c) and bisected, showing macroscopic (d) and microscopic evidence of caseous necrosis (e). A diagnosis of tuberculous adenitis was therefore established. The patient was subjected to a purified protein derivative (PPD) skin test that was positive. k k Sialolithiasis 123 (a) (b) Figure 5.8. A panoramic radiograph demonstrating calcifications within the left submandibular region (a). At first glance of the radiograph, submandibular sialolithiasis is a reasonable consideration. Close examination of the radiograph reveals multicentric lamellated calcifications in the submandibular and preauricular regions, as well as a calcification superimposed on the left mandibular second molar roots. A complete physical examination revealed signs consistent with a hemangioma associated with the left mandibular gingiva (b). As such, the calcifications are presumed to represent phleboliths, and are not removed. It is important, therefore, to diagnose sialolithiasis based on a review of a radiograph as well as a physical examination. SUBMANDIBULAR SIALOLITHIASIS thereby preventing recurrence and allowing for healing of the gland (Rontal and Rontal 1987). The treatment of salivary calculi of the sub- A properly performed sialodochoplasty ensures k mandibular gland is a function of the location and effective flow of saliva from the gland in hopes k size of the sialolith (Figure 5.10). For example, of maintaining the health of the salivary gland. sialoliths present within the duct may often be This procedure involves suturing the edges of retrieved with a transoral sialolithotomy pro- the duct’s mucosa to the surrounding oral mucosa cedure and sialodochoplasty. In general terms, (Figure 5.11). The number of sutures placed is arbi- if the stone can be palpated transorally, it can trary; however, a sufficient number of sutures is probably be removed transorally. A review of 172 required so as to stabilize the reconstructed duct to patients who underwent intraoral sialolithotomy the floor of mouth. Proper postoperative hydration of a submandibular stone assessed results as of the patient with free flowing saliva maintains to complete removal, partial removal, and fail- patency of the sialodochoplasty, thereby enhanc- ure (Park, et al. 2006). The effect of location, ing the potential for reversal or stabilization of the size, presence of infection, and palpability of the underlying sialadenitis. Chronic submandibular calculi on the results was assessed. Univariate obstructive sialolithiasis clearly leads to chronic analysis showed that palpability and the presence sialadenitis with presumed parenchymal destruc- of infection were statistically significant factors tion. After removal of the sialolith, however, the affecting transoral sialolithotomy. Palpability apparent resiliency of the submandibular gland was the only significant factor after multivariate usually results in no adverse symptoms (Baurmash analysis. This study provides scientific evidence 2004). As such, the ability to effectively retrieve a supporting intraoral removal of extraglandular sialolith usually refutes the need to also remove the submandibular gland stones regardless of loca- affected salivary gland. Sialoliths located within tion, size, presence of infection, or recurrence of the submandibular gland or its hilum are most calculi as long as the calculi are palpable. This commonly managed with submandibular gland procedure involves excising the Wharton duct excision (Figure 5.12). This controversial statement overlying the stone thereby permitting its retrieval is made based on the relative difficulty to retrieve (Figure 5.11). Reconstruction of the duct in the stones from this anatomic region of the gland, form of a sialodochoplasty permits shortening rather than based on the assumption that prox- of the duct and enlargement of salivary outflow imal stones cause permanent structural damage k k 124 Chapter 5 (a) (b) k k (c) (d) Figure 5.9. This panoramic radiographic close-up shows an irregular mass associated with the left submandibular region (a). Computerized tomograms were not obtained preoperatively, and a differential diagnosis of submandibular sialolithiasis was established. The calcification, however, does not show typical radiographic signs of a sialolith, including its irregular borders. The patient underwent exploration of the left submandibular region, whereupon the calcified mass was identified as a distinct entity from the left submandibular gland (b). The mass was removed (c) and the left submandibular gland remained in the tissue bed (d).
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