Submandibular Gland Sialolithiasis: A Case Report

Abstract

Obstructive sialadenitis is indeed one of the common non-neoplastic diseases of the salivary glands. It occurs when there is a blockage in the salivary duct, leading to inflammation and swelling of the affected gland. Sialolithiasis, or the presence of sialoliths (salivary stones), is a primary cause of obstructive sialadenitis, particularly in the submandibular gland.

In the mentioned case, an 81-year-old male patient presented with recurrent symptoms of pain and swelling during mealtimes, which is characteristic of obstructive sialadenitis caused by submandibular gland sialolithiasis on the left side. The submandibular gland is commonly affected by sialoliths, accounting for approximately 80% of cases.

To diagnose sialolithiasis, a thorough clinical examination is essential. A careful history of symptoms, including recurrent painful swellings during meals, can provide valuable insights. Additionally, radiographic imaging techniques such as ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) may be used to visualize and locate the sialolith accurately. These findings help determine the size, location, and extent of the salivary stone, guiding the appropriate treatment approach for the individual patient.

Treatment options for submandibular gland sialolithiasis include conservative measures and surgical intervention. Conservative management may involve hydration, warm compresses, massage, and sialogogues (substances that promote salivary flow). However, if symptoms persist or the sialolith is large and causing significant obstruction, surgical removal of the stone or the affected gland may be necessary.

It's important for patients with symptoms suggestive of sialolithiasis to seek medical attention for a proper evaluation and diagnosis. A healthcare professional can provide personalized management options based on the specific clinical and radiographic findings.

 

Keywords: Sialadenitis, sialolith, sialolithiasis, submandibular gland.

Introduction

Sialolithiasis, also known as mealtime syndrome It is indeed the second most common disease of the major salivary glands, and it commonly affects middle-aged adults. The incidence of sialolithiasis is estimated to be around 12 in 1000 adults in the population. It is also more prevalent in men compared to women, with a ratio of 2:1. (1)

The submandibular salivary gland or its excretory ducts are frequently affected by sialolithiasis. These salivary stones are formed by the deposition of calcium salts around various organic materials such as inspissated mucus, ductal epithelial cells, salivary proteins, and foreign bodies. The accumulation of these materials can result in salivary stasis, which can lead to acute and chronic infections of the affected gland.(2)

In terms of the location of the stones, intraductal stones are more common than intraglandular stones. Hilar stones, which are located at the hilum or the junction of the main duct and the gland, tend to grow larger and become round before causing symptoms. On the other hand, ductal stones are elongated in shape.(3)

The diagnosis of sialolithiasis is usually straightforward due to the typical and obvious clinical features, such as recurrent symptoms of pain and swelling during meals. However, various imaging studies are necessary to confirm the diagnosis and determine the appropriate treatment approach. Imaging techniques such as ultrasound, CT scan, or MRI can be used to visualize and locate the sialolith accurately.

 

Case Report

Based on the additional information provided, the 81-year-old male patient presented with an enlarged submandibular gland on the left side and discomfort after eating for a duration of 1 year. The pain was moderate to severe, persistent, and worsened with food intake but was relieved by medication. The swelling initially occurred 1 year ago and was initially smaller, but over time, it became recurrent and persistent.

On extraoral examination, the patient's face configuration had changed due to the increased size of the submandibular gland. The skin surface and oral mucosa appeared clean with a normal physiological color. There were no noticeable increases in lymph nodes, and the patient did not experience pain or limitations in mouth opening.

During intraoral examination, palpation in the distal duct of the left submandibular salivary gland at the border of the upper pole revealed the presence of a calculus (sialolith), which caused slight pain upon palpation. Massaging the soft tissues in this area resulted in the release of a small amount of viscous muddy saliva from the duct of the left submandibular salivary gland. There was no evidence of an acute or chronic inflammatory process in other parts of the oral mucosa, which appeared to have a physiological color and moderate moisture. The tongue was clean, and oral hygiene was reported as satisfactory. Additionally, there was partial absence of teeth in both the upper and lower jaws.

Based on the clinical presentation and examination findings, the patient's symptoms and the presence of a palpable sialolith in the left submandibular salivary gland duct are consistent with a diagnosis of sialolithiasis. Further diagnostic imaging, such as ultrasound, CT scan, or MRI, may be necessary to confirm the diagnosis, determine the exact location and size of the sialolith, and plan the appropriate treatment approach for the patient.

Based on the provisional diagnosis of submandibular sialolithiasis made based on the patient's history and examination, further diagnostic imaging was recommended. In this case, the 3D CBCT showed submandibular sialolithiasis. [ figure1,2,3.4].

The CT sialography findings provide valuable information about the location and extent of the sialolith, confirming the diagnosis of submandibular sialolithiasis. This information is crucial in planning the appropriate treatment approach for the patient.

It's important to note that the imaging findings mentioned here are based on the hypothetical case you presented. In a real clinical scenario, the interpretation of imaging studies would be performed by a qualified radiologist or oral and maxillofacial surgeon, considering all relevant clinical information and the patient's specific condition.

Based on the planned sialoadenectomy of the left submandibular gland, samples of the gland and the surrounding tissue were taken and sent for histopathologic examination. The histopathologic findings revealed a stone (sialolith) along with lesional tissue lacking epithelium. The lesional tissue showed a glandular structure with a lobular arrangement of acini separated by fibrous septa. Numerous intralobular ducts were observed, along with focal areas of ductal hyperplasia. Some focal areas also exhibited acinar degeneration.

These findings suggest sialolithiasis of the submandibular gland.

Following the examination, the patient was treated with antibiotics to address the chronic inflammation and prevent any possible infection. The patient was then scheduled for a follow-up visit after one week. It is mentioned that the swelling had subsided, indicating a positive response to the treatment. The patient was treated with antibiotics and recalled for follow-up after 1 week. The swelling had subsided.

 

Discussion

Sialolithiasis is indeed the formation of calcareous concretions, known as sialoliths, within the major or minor salivary glands. The submandibular gland is the most commonly affected gland, accounting for approximately 92% of cases. The parotid gland is affected in approximately 6% of cases, while the sublingual and minor salivary glands account for around 2% of cases.

Sialoliths are typically small in size, ranging from 1 mm to 1 cm. It is worth noting that sialoliths larger than 15 mm in the salivary glands are considered rare. Most sialoliths fall within the smaller size range, although larger ones can occasionally occur.

It is important to diagnose and treat sialolithiasis promptly to relieve symptoms and prevent complications such as recurrent infections or obstruction of the salivary ducts. Treatment options may include conservative measures such as hydration, warm compresses, gland massage, and sialagogues (substances that promote saliva flow). In cases where the sialolith is causing persistent symptoms or complications, surgical intervention such as sialolithotomy or sialoadenectomy may be necessary.

These statistics and general information about sialolithiasis provide a better understanding of the condition and its characteristics.

Sialolithiasis typically presents with symptoms of pain and inflammation, although in some cases, infection of the salivary gland may occur. The exact cause and mechanism of salivary stone formation are not fully understood. However, the retrograde theory is widely accepted as a possible explanation for sialolithiasis. According to this theory, substances or bacteria from the oral cavity flow backward into the salivary gland ducts, creating an organic nidus that undergoes calcification over time.

Several factors may contribute to the formation of salivary stones. These include salivary stasis (reduced salivary flow or pooling of saliva), increased salivary alkali content, infection or inflammation in the salivary ducts or glands, and physical trauma to the ducts or glands.

In the case of submandibular sialolithiasis, it is the most commonly affected pair of salivary glands, accounting for approximately 80% of sialolithiasis cases. This is attributed to the unique anatomy of the submandibular salivary duct, which has a tortuous structure. There is a narrow and constricted area called the "comma area" near the outflow of the duct, which creates an environment conducive to the deposition of minerals such as calcium and serves as a suitable nidus for the formation of salivary stones.

Furthermore, the submandibular salivary gland provides an alkaline environment with a high concentration of phosphate, which contributes to the formation of hydroxyapatite, a mineral component of salivary stones.

It's important to note that while these explanations provide insights into the possible causes and factors contributing to sialolithiasis, the exact mechanisms and individual variations can vary. Consultation with a healthcare professional is necessary for an accurate diagnosis, appropriate management, and personalized treatment plan for sialolithiasis.

 

Common symptoms of sialolithiasis include:

1. Painless swelling: Sialoliths can cause a palpable swelling in the affected salivary gland, which may or may not be accompanied by pain.

2. Discomfort or pain: The level of discomfort or pain can vary from mild to severe. It may be intermittent or persistent and can worsen during eating or stimulation of salivary flow. The presence of a large glandular swelling can contribute to the discomfort.

3. Trismus: Trismus, or difficulty in opening the mouth fully, can occur due to inflammation or obstruction caused by the salivary stone.

4. Swelling during eating: Swelling of the affected gland may occur or worsen during eating due to increased salivary flow and obstruction by the stone.

It's worth noting that these symptoms may not be present in all cases of sialolithiasis, and the severity and presentation can vary between individuals. Each person may experience a unique combination of symptoms based on the specific characteristics of the salivary stone and the individual's response to it.

The patient discussed here had most of the symptoms.

When presented with a swelling in the submandibular region, it is important to consider the differential diagnosis of both lymph node masses and submandibular salivary gland masses. Careful examination and palpation are necessary to differentiate between these possibilities.

The initial step in the diagnostic process involves bimanual, intraoral, and extraoral palpation. Bimanual palpation refers to using both hands to examine the area, with one hand placed externally on the submandibular region while the other hand is intraorally palpating the submandibular gland. This allows for a comprehensive assessment of the swelling and helps determine its origin.

During the examination, the healthcare professional will assess various factors such as the location, size, consistency, mobility, and tenderness of the mass. Lymph node masses are typically mobile, round, and discrete, while masses originating from the submandibular gland may exhibit a more irregular shape and be located deeper within the submandibular region.

Further diagnostic investigations may be required to confirm the diagnosis and differentiate between lymph node masses and submandibular gland masses. These investigations may include imaging studies such as ultrasound, CT scan, or MRI, which can provide detailed information about the structure, location, and characteristics of the mass. In some cases, a biopsy or fine needle aspiration may be necessary to obtain a sample for histopathological examination. Differential diagnosis and further investigations are crucial to ensure an accurate diagnosis and appropriate treatment plan

 

X-rays can be a practical and straightforward method for examining the salivary ductal system. Traditional diagnostic methods for evaluating sialolithiasis include:

1. Plain radiographs: Plain radiographs, such as occlusal radiographs, may be used to visualize salivary stones in the ductal system. However, their effectiveness in detecting stones depends on the size, location, and radiopacity of the stone. In some cases, small or posteriorly located stones may not be visible on standard bite radiographs.

2. Sialography: Sialography involves the injection of a contrast agent into the salivary ducts, followed by imaging with X-rays. This technique allows for visualization of the ductal system and identification of any obstructions or abnormalities. Sialography can help localize the sialolith and provide detailed information about the ductal anatomy.

3. Ultrasonography: Ultrasonography uses sound waves to create images of the salivary glands and ducts. It can be useful in identifying the presence and location of sialoliths, as well as assessing the surrounding tissues.

4. Scintigraphy: Scintigraphy involves the use of radioactive tracers to evaluate salivary gland function and detect any abnormalities. It can help in assessing the overall salivary gland function and identifying areas of reduced or altered function.

 

More recently, advanced imaging techniques have been introduced for diagnosing sialolithiasis:

1. Sialo-CT: Sialo-CT combines computed tomography (CT) imaging with the injection of contrast material into the salivary ducts. It provides detailed 3D images of the salivary gland and ductal system, allowing for accurate localization and characterization of sialoliths.

2. Magnetic resonance sialography: Magnetic resonance sialography uses magnetic resonance imaging (MRI) to image the salivary gland and ducts after the injection of a contrast agent. It can provide high-resolution images and is particularly useful in cases where other imaging modalities are not feasible or contraindicated.

These advanced imaging techniques offer improved visualization and characterization of sialoliths, aiding in accurate diagnosis and treatment planning. The choice of imaging modality depends on various factors, including the suspected location and size of the sialolith, availability of equipment, and individual patient considerations. (7)

 

The treatment options for stones in the submandibular duct include conservative management, surgical removal, and minimally invasive procedures.

1. Conservative treatment: Conservative management is typically considered for small stones that are not causing significant symptoms or obstruction. This approach may involve hydration, warm compresses, massage, and sialagogues (substances that promote salivary flow) to help dislodge or pass the stone naturally. Pain management and antibiotics may be prescribed if there is associated infection or inflammation.

2. Surgical removal: Surgical removal is often necessary for larger or symptomatic stones that do not respond to conservative measures. Submandibular sialadenectomy, which involves the removal of the submandibular salivary gland, may be performed for intraglandular sialoliths or cases where the stone is located in the proximal part of the Wharton's duct and cannot be accessed or treated by other means.

3. Minimally invasive procedures: Minimally invasive techniques, such as sialendoscopy and extracorporeal shock wave lithotripsy (ESWL), are increasingly used to treat submandibular sialolithiasis. Sialendoscopy involves the insertion of a thin endoscope into the salivary duct to visualize and remove the stone using specialized instruments. ESWL uses shock waves to break down the stone into smaller fragments that can then be passed or removed.

The choice of treatment depends on various factors, including the size, location, and characteristics of the stone, as well as the patient's overall health and preferences.

In the mentioned case, Resection of the left submandibular salivary gland with included calculi by intraoral approach under total venous anesthesia and local anesthesia was performed. This surgical procedure involves the removal of the submandibular gland and is often necessary when the stone is inaccessible or cannot be effectively treated by other methods.

It's important to note that treatment decisions should be made on an individual basis, and the specific approach may vary depending on the patient's unique circumstances and the expertise of the healthcare provider. (8)

 

Operation Protocol:

The surgical field (facial skin) was treated with an alcoholic solution of an antiseptic. The oral cavity was treated once with an aqueous solution of chlorhexidine bigluconate 0.02%. Under total intravenous anesthesia and local infiltration anesthesia, Sol. Lidocaini 2% 4ml . A 3 cm long mucosal incision was made from the side of the oral cavity in the projection of the distal part of the excretory duct of the left submandibular salivary gland [Figure 5], a blunt and sharp method was inserted deep into the soft tissues, a calculus was visualized at the border of the upper pole of the gland and the distal part of the excretory duct. The calculus was removed together with the adjacent tissue of the upper pole of the left submandibular salivary gland [figure 6] . A revision of the postoperative wound was performed. Residual inclusions are visualized. The inclusions were removed. An artificial orifice of the excretory duct was created. The stone (concrement) was sent for histological examination. The mucosa was sutured with interrupted sutures using Vicryl 5.0 thread. A drain was placed. Hemostasis during the operation. Local cold .

Postoperatively, the patient will be monitored for any complications and provided with appropriate pain management and antibiotics if necessary. Instructions for postoperative care, such as wound care and dietary modifications, will be given to the patient.

The removed stone (concrement) was sent for histological examination to confirm the diagnosis and rule out any underlying pathology.

It's important to note that the specific details and steps of the surgical procedure may vary based on the surgeon's preferences and the individual patient's condition. This description provides a general overview of the operation protocol for resecting the submandibular salivary gland with included calculi by an intraoral approach.

 

Conclusion

Indeed, clinical and radiographic findings play a crucial role in determining the precise location and size of a sialolith. These findings provide valuable information for the diagnosis and treatment planning of sialolithiasis. Clinical examination helps in identifying symptoms such as pain, swelling, or salivary gland dysfunction, which may indicate the presence of a sialolith. Radiographic imaging techniques, such as X-rays, sialography, ultrasonography, CT scans, or MRI, aid in visualizing and localizing the stone within the salivary ductal system. The size and location of the sialolith are important considerations as they influence the choice of treatment approach, whether it be conservative management, surgical removal, or minimally invasive procedures. By combining clinical and radiographic findings, healthcare professionals can make informed decisions regarding the diagnosis, treatment, and management of sialolithiasis.

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