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A Hard Calculus: Submandibular Sialolithiasis

 

An oblique x-ray view of the patient's mandible showing a radiopaque stone in the submandibular duct (upper arrow). The lower arrow is pointing to the hyoid bone, which served as an anatomic reference point.

An oblique x-ray view of the patient’s mandible showing a radiopaque stone in the submandibular duct (upper arrow). The lower arrow is pointing to the hyoid bone, which served as an anatomic reference point.

Eating worsened the discomfort a 52-year-old woman was experiencing, who presented with a 4-day history of painful swelling on the left side of the neck. The consumption-related symptom is common among those with her diagnosis.

Assessment

A tender, firm, warm swelling was identified in the patient’s left submandibular region. Intraoral examination revealed a hard distension, suggestive of a sialolith, in the left Wharton’s duct. An x-ray of the mandible, obtained in the lateral-oblique view, confirmed the presence of a stone (Figure 1).

Diagnosis

Sialolithiasis refers to the formation of calculi within a salivary gland or its duct. The term is derived from the Greek words sialon (saliva) and lithos (stone). The submandibular gland is most commonly affected, accounting for up to 85% of cases; 5% to 10% occur in the parotid gland, and 1% to 5% form in the sublingual gland or minor salivary glands.1 Stones usually present with intermittent pain. Eating exacerbates symptoms because the extra saliva produced with chewing gets ensnared in the gland. Some patients have a palpable gland in the neck, along with erythema and pus discharge from the duct opening under the tongue.

The exact cause is unclear. Dehydration, reduced salivary flow, and aberrations in calcium metabolism are believed to contribute. Altered solubility of crystalloids, which leads to precipitation of mineral salts, is another likely factor. The diagnosis can be confirmed with x-ray, a sialogram, or ultrasound.

Management

Small, peripherally located stones in the duct can be removed via massage. The stone can come out as a single piece or in fragments that are intermittently expelled. Surgical removal from the gland or duct is another option and can be accomplished directly or by using a sialendoscope, a minimally invasive endoscope.

Our patient had the stone surgically removed (Figure 2). Her submandibular swelling resolved, and at the 3-month follow-up, she was asymptomatic.

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-Satvinder Singh Bakshi, MS, DNB

This article originally appeared in the February 2017 issue of The American Journal of Medicine.

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