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Oral Surgery

Authors: Dr. Alberto Benedetti, Dr. Jasmin Fidoski, Dr. Aleksandar Stamatoski

INTRODUCTION:

Sialoliths are calcareous concentrations and most salivary calculi occur in the submandibular glands or ducts (80-95%), whereas 5-20% occur in parotid gland1-4. The sublingual glands are rarely (1-7%) affected1-4. They are usually unilateral with clinically round or ovoid, rough or smooth yellow in colour. Males are twice more affected than females1,2. Etiological factor and pathogenesis of salivary calculi is unknown, but the inflammation factor is widely accepted2,5. Mostly, salivary calculi clinically are characterized by local pain, swelling, less saliva production, dry mouth. Sometimes when the salivary calculi become large enough, dysphagia, difficulty in speech, lymphadenopaty of involved area are presented.

Basic imaging methods are ortopantomogramic and mandibular occlusal views, followed by computed tomography may assist the diagnostic protocol and best treatment. Differential diagnosis of other diseases, such as epidemic parotitis-mumps, obstructive sialoadenitis and benign or malignant salivary gland tumors could be verified to established and eliminate them. The literature presents different sizes and shapes of silaloliths, but giant sialolith of submandibular gland and duct are rarely reported (>4mm). The location and dimensions of sialolith will determinate the management modalities, conservative or surgical procedure.
 
Fig. 1 Preoperative CT-scan shows large radiopaque mass localized within
the left submandibular gland Fig. 2 Enucleated salivary stone having unusual size and shape
Fig. 1 Preoperative CT-scan shows large radiopaque mass localized within the left submandibular gland Fig. 2 Enucleated salivary stone having unusual size and shape
 
2 7
2 7


CASE REPORT

A 67-year-old man sought medical attention with complaint of pain, swelling in the posterior part on the left side of the mouth floor, dry mouth with bad breath and dysphagia. He also complained on inability to eat and drinking in some periods during last 3-4 months with a period of minor black saliva in the morning. During the anamnesis, the patient gave as a past medical history of arrhythmia, high blood pressure and bronchitis, and took Aspirin (salicylate drug), Diazepam (benzodiazepine), Losartan (angiotensin 2 receptor blockers) and Verapamil ( calcium channel blockers).

The patient was a smoker. A clinical examination revealed tenderness and palpable hard mass on the left submandibular region followed by regional lymphadenopathy. An occlusal radiograph was advised, but because of posteriorly placed lesion could be seen a half-oval sialolith on compatible image in the lower left premolars and molars region. The orthopantomogram radiographic examination view revealed big triangle radio-opaque mass, confirming the diagnosis of major submandibular sialolith. At the same patient was performed computerized tomography in two projections: posterior-anterior and right-left, definitely to diagnose the submandibular sialolith (Fig.1).

Patient was planned for extraoral surgery under general anesthesia. Siaolodenectomy (to remove the submandibular gland) was performed via extraoral approach and preservation of the nearby structures. During surgical procedure one little part of the sialolith was broken. The sialolith was present in the parenchyma of the submandibular gland, measuring 45x35 mm and 10 g in weight (Fig.2). Histopathological examination of the submandibular gland shows chronic submandibular sialedenitis. All of symptoms of the patient disappeared after surgery procedure. He was discharged from the hospital on the third postoperative day.
 
CAM00291 CT neck P-A
CAM00291 CT neck P-A
 
occlusal
occlusal


DISCUSSION

Salivary calculi are usually small and measure from 1 mm to less than 1 cm, and they rarely measure more than 1.5 cm1,2,5. Giant sialoliths which size is more than 3.5cm are rare and can be found in the body of submandibular gland. According to Iqbal et al.,1 the submandibular gland is most involved because it’s specific anatomical location and long tortuous duct. Sialoliths are usually manifesting between the third and sixth decade of life1,3,5,6. It’s believed that sialoliths annually increase by 1-1.5 mm per year1,2. There are cases of large salivary calculi presented in the literature. Iqbal et al.,1 reported a sialolith from the left submandibular duct of 55-year-old man measuring 35mm in length and 30mm circumference.

Fowell and MacBean3 removed irregular elongated submandibular sialolith, weighing 3.0g and measuring 41 mm in 58-year-old male patient with history of pain within weeks. Krishnappa6 removed multiple submandibular duct calculi of unusual size and shape in a 42-year-old male patient. Alkurt and Peker5 reported two cases of unusually large submandibular sialoliths in 45 and 65 year old man, with lesion size in the first case 2.8 × 0.8 × 0.4 cm and 3.1 × 1.0 × 0.7 cm second case. Singhal and al.,2 reported that patients who had multiple calculi in major salivary gland can be located in different anatomical location as well as salivary duct or body of salivary gland. The etiology and pathogenesis of major salivary calculi are still unknown1,2.

These includes infective, increased alkalinity Ph and calcium content of the saliva, inflammatory, infective, mucus or desquamates cells, using certain medication that affects production of saliva 3,4,7,8. Most common symptoms are recurrent pain, swelling of the involved salivary gland and pus secretion1,5,9,10. There are various clinical and X-ray imaging methods that are available to detect and visualize the radiopaque stone like occlusal views, panoramic views and computerized tomography2,7.

Parkar and al.,4 showed that radiopaque in X-ray imaging have been reported in 80-94.7% of cases. The treatment depends on size and location of sialolith, and treatment options for salivary calculus are generally dictated by the position of the stone. Intraglandular or sialoliths located in the body of major salivary glands require sialodenectomy or partial parotidectomy, when they are located in parotid gland. In our case, the giant submandibular sialolith was removed with open extraoral surgery under general anesthesia.
 
OPG
OPG


CONCLUSION:

Clinical investigation followed by diagnostic methods is especially important to determine the existence of salivary calculi. Giant salivary gland calculi might be asymptomatic or followed by local pain and swelling in the affected area. The location and dimensions of sialolith determinate the management modalities but surgical treatment of giant salivary gland calculi is necessary.

Financial supports or source

Nil.

Conflict of interest

The authors have no conflict of interest towards the preparation of this manuscript.

Acknowledgement

The presented study has been carried with interdisciplinary assistance of all authors.

References
 
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  2. Singhal A, Singhal P, Ram R, and Gupta R. Self-exfoliation of large submandibular stone-report of two cases. Contemp Clin Dent. 2012 Sep; 3: S185–S187. doi: 10.4103/0976-237X.101087.
  3. Fowell C and MacBean A. Giant salivary calculi of the submandibular gland. J Surg Case Rep. 2012 Sep 1;2012(9):6. doi: 10.1093/jscr/2012.9.6.
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  8. Jung JH, Hong SO, Noh K, and Lee DW. A large sialolith on the parenchyma of the submandibular gland: A case report. Exp Ther Med. 2014 Aug; 8: 525–526. Published online 2014 May 26. doi: 10.3892/etm.2014.1730.
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