International Journal of Dental and Health Sciences Case Report Volume 04, Issue 02

INTRAORAL REMOVAL OF SALIVARY STONE FROM THE PROXIMAL DUCT: A CASE REPORT Sujeesh Koshy1, Eapen Thomas2, Ravi Rajan Areekkal 3, Akhilesh Prathap4 1.Senior Lecturer, Department of Oral And Maxillofacial Surgery, Pushpagiri College of Dental Sciences 2.Professor and Head of The Department Department of Oral And Maxillofacial Surgery, Pushpagiri College of Dental Sciences 3.Post Graduate Student Department of Oral And Maxillofacial Surgery, Pushpagiri College Of Dental Sciences 4.Reader, Department of Oral And Maxillofacial Surgery, Pushpagiri College of Dental Sciences

ABSTRACT: is the most common cause of salivary gland and about 80% to 90% of stones occur in the submandibular gland. The majority of sialoliths occur in the submandibular gland or its duct and are a common cause of acute and chronic . 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. Size varies from 10-15 mm. We present a case of 57-year-old female who reported to us with the complaint of pain and swelling, on the left side floor of the mouth. Based on the radiographic (sialography) and clinical examination a diagnosis of sialolithiasis of the left submandibular duct was made. The sialolith was removed under general anesthesia. Keywords: Saliva, Sialolith, Wharton’s Duct, submandibular gland (SMG)

INTRODUCTION male predominance.[3] Approximately 80% of sialoliths are reported to be less than Sialolithiasis is characterized by the 10 mm in size, and a review of the development of salivary stones, known as literature has shown the occurrence of salivary calculi or sialoliths in the salivary abnormally large sialoliths (more than 15 duct or in the salivary gland. More than mm) to be rare. [1, 2] 80% of salivary sialoliths occur in the submandibular gland, 6-15% in the Salivary calculi develop due to deposition parotid gland and around 2% occur in of mineral salts around a nidus of sublingual and minor salivary gland.[1,2] , desquamated cells or mucus. Among them, 40% of the SMG stones are Sialoliths are composed of organic and located in the distal submandibular duct inorganic substances. The organic layer is near the punctum, and they are removed composed of condensed mucus, through the intraoral approach. The other mucopolysaccharides, glycoproteins, 60% of the SMG stones are located in the cellular elements and lipids while the proximal submandibular duct or in the inorganic material is composed of calcium submandibular gland, and they usually are phosphate, calcium carbonate, and trace removed by transcervical SMG resection. elements. The etiology of sialolith is Frequency of occurrence is 1.2%, with assumed to be related to the specific

*Corresponding Author Address: Dr. Sujeesh Koshy Email: [email protected] Koshy S et al., Int J Dent Health Sci 2017; 4(2): 366-370 physiological and anatomic factors of the On the basis of clinical and radiographic affected gland. The incidence of examination, diagnosis of sialolithiasis was sialolithiasis in the sublingual gland is very made. Analgesics and antibiotics were rare and in some studies absent. 80 to given preoperatively, after which surgical 90% of sialoliths develop in the removal of the sialolith from intraoral submandibular gland due to viscous approach was planned. consistency of saliva, high pH, high Under general anesthesia sialolithotomy calcium concentration and mucin was performed from intraoral approach. content. Moreover, Wharton’s duct has Before placing the incision a knot was an antigravity flow, long irregular course placed behind the expected position of and a small opening that facilitates stasis the stone on the duct. This helped to of saliva. The chemical composition prevent the slipping of the consists of microcrystalline apatite or further posterior during manipulation. whitlockite.[4,5] Submandibular stones are (Figure 2) Sialolith was exposed by made up of 82% of inorganic and 18% of placing an incision on the floor of the organic material, whereas parotid stones mouth and dissecting the duct to a are formed of 49% inorganic and 51% desired length proximally and distally organic material.[6] We report a case of a (Figure 3). Followed by which the duct salivary duct stone of unusual size in a 57- was palpated for the presence of hard year-old male patient and discuss its prominence. Next an incision was placed surgical management. on the prominence and the calculus was CASE DETAIL: removed. A 4 mm diameter round, rough, hard, yellowish colored mass was A 57-year-old female reported with a chief obtained (Figure 4). The duct was sutured complaint of swelling, and pain on the passively followed by the floor of the left side floor of the mouth since 2 mouth using absorbable suture (Figure 5). months. The patient’s medical history was Patient was discharged on the third noncontributory. Pain was continuous and postoperative day and was on the follow- sharp in nature, pricking in type, radiating up for 6 months. She showed no signs or to the tongue with restricted tongue symptoms of xerostomia, and salivary movement. Extraoral examination was flow was normal. insignificant. Intraoral examination revealed tenderness along the left DISCUSSION: Wharton’s duct. Occlusal radiograph Sialoliths commonly measure around 5-10 revealed no significant findings in the duct mm in size and are mainly made up of region. To rule out obstructions calcium phosphate with small amounts of sialographic images were taken. The carbonates in the form of images showed an obstruction in the hydroxyapatite.[7] Typical presentation of proximal duct with a radioopacity sialolithiasis is pain and swelling of the measuring about 4mm. (Figure 1) involved salivary gland caused by

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Koshy S et al., Int J Dent Health Sci 2017; 4(2): 366-370 obstruction of salivary flow.[8] The pain tomography scan, ultrasound) may be and swelling usually occur during meals. required for locating them.[12] Larger Because sialoliths are usually sialoliths appear as radiopaque masses symptomatic, patients often receive and are easily seen on radiographs.[9] medical attention long before a sialolith The location, size, and configuration of becomes large. A growing sialolith the sialolith are important factors when increases obstruction of salivary secretion, planning intervention for a giant which leads to various complications, such sialolith.[6] The goal of treatment for a as swelling, pain, and secondary giant sialolith, as well as for a standard- of the gland, and finally to the need for size sialolith, is restoration of normal surgical intervention. [2] salivary secretion. Although chronic A nidus, salivary stagnation and secondary to persistent precipitation of salivary salts are obstruction from a sialolith leads to a necessary for the formation of sialolith. fibrotic and poorly functioning gland, Infection, of the gland, symptoms apparently resolve after physical trauma to the duct or orifice or sialolith removal.[7] presence of desquamated epithelial cells Sialoliths should be removed by the least are involved in the development of invasive procedure available to avoid risk salivary stones.[9] According to Ledesma of complications. Sialolithotomy is a well- Montes et al.[10] salivary proteins might reported technique for the transoral also play an important role in sialolith removal of a ductal sialolith, including formation Marchal et al.,[11] observed the giant sialoliths, without duct stenosis and presence of a sphincter system in the first lingual nerve damage.[13,17] However, as 3 cm of the Wharton’s duct in 90% of their for the transoral removal of a proximal studied cases, and suggested that sialolith, it has been reported that there is variation of such a sphincter-like increased risk of lingual nerve damage.6 mechanism in the salivary duct could be a According to Rai and Burman[7] a large reason for easier retrograde migration of sialolith should be removed by transoral oral materials. In our case, the sialolith sialolithotomy. Longterm obstruction by was located in the submandibular gland large sialoliths may cause salivary gland that is most susceptible to calculus sialadenitis gland.[14] However, our patient formation due to a greater concentration after 6 months of sialolithotomy, showed of calcium and phosphate, alkalinity of its no signs or symptoms of xerostomia with saliva with higher mucus content. normal salivary flow. According to Soares Moreover, it has a tortuous course, et al. [15] intraductal stones can be causing tendency for secretory congestion removed by transoral approach, and an and calculus formation.[9] Radiopacity is extraoral submandibular gland excision is not a consistent feature in most of the indicated for intraglandular stones. submandibular stones; hence sialography Treatment of sialolith of a remarkable size or other imaging techniques (computed

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Koshy S et al., Int J Dent Health Sci 2017; 4(2): 366-370 is challenging for the clinician. The clinicians should carefully evaluate Conservative methods of treatment such the swelling in the submandibular area as endoscopy, shockwave lithotripsy due to sialolith that is most common in the submandibular gland and Wharton’s techniques should be considered as a duct. Larger submandibular sialolith substitute to surgical excision, especially should be treated by an appropriate [16] for small calculi. approach to prevent complications.

CONCLUSION:

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Koshy S et al., Int J Dent Health Sci 2017; 4(2): 366-370 obstructive sialadenitis associated 2004; 33:300-304. with sialolithiasis. J Oral Pathol Med.

FIGURES:

Fig 4 : removed salivary stone

Fig 1 : sialographic image of salivary calculus

Fig 5 : sutured surgical site

FIG 2 : Knot being tied on the distal duct

Fig 3 : dissection of the distal proximal duct

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