UNUSAUAL PRESENTATION OF SUBMANDIBULAR DUCT AND GLAND CALCUI: CASE - PDF document

Volume 3 Issue 1 2013 ISSN: 2250-0359 UNUSAUAL PRESENTATION OF SUBMANDIBULAR DUCT AND GLAND CALCUI: CASE REPORT *KIRAN J SHINDE *SACHIN SHARMA *AMIT KUMAR SINGH *RMC LONI Maharashtra Abstract Sialolithiasis is one of the most common pathologies of the submandibular gland; sialoliths account for about 80 percent of all salivary duct calculi.The majority of sialolith occurs in the submandibular gland or its duct and is common cause of acute and chronic infection. Salivary stones larger than 15 mm are classified as giant sialoliths. They are uncommon in the practice of otolaryngology, and their management has always been a therapeutic challenge. This report presents the two unusual and rare cases of large sialolith of the submandibular duct as well as gland measuring 70x11mm and 54x25mm respectively. Introduction frequent clinical presentation is swelling and pain in the area of the affected gland with a prodromal awareness varying from less than Salivary gland ⁄ duct stones or sialoliths are six months to 30 years. Sialoliths can often be calcifications that accumulate within the detected on palpation, especially when they salivary gland parenchyma and associated are located above the mylohyoid muscle or in ductal systems. They develop from a the buccal mucosa and lip 2- 4 . Sialoliths in the mineralization nucleus of debris including submandibular gland duct are usually bacterial colonies, shed ductal epithelial cells diagnosed after longer asymptomatic periods and cell remnants, mucus plugs and foreign than those in the parotid gland duct 2-4 . bodies 1 .Eighty to 90 per cent of sialoliths develop in the submandibular gland system, Case report: and 10 – 20 per cent in the parotid gland. Only 1 per cent of calcifications occur in the Case 1: sublingual gland which may be due to a A 26-year-old male presented at the dominant mucoid secretion and very short ductal tree 2 . Most patients present with a department of ENT, Rural Medical College, Loni with complaints of 1) severe pain and swelling single stone but multiple stones occur in 32 per cent of cases in the parotid gland and 22 per in the right lower submandibular region for a duration of 7 days. There were episodes of pain cent in the submandibular gland. Bilateral in the same region for last 2 years but of a stones occur in around 2.2 per cent of cases. moderate intensity that the patient could Sialoliths are typically more common in tolerate. Presently, his pain was intermittent, middle-aged males but some studies suggest a male to female ratio of 1:1 and with ages of the pricking type and sharp in nature, ranging from 12 to 93 years 4 . The most radiating to the tongue. The pain became

aggravated during eating and was relieved by Case 2: rest. Swelling was gradual in onset, progressing A 44-year-old man presented at the to the present size. There were occasions of department of ENT, Rural Medical College, Loni mild swelling during meals for the last 6 with the compliant of swelling, in his left months, which the patient had been ignoring. submandibular region that had been present 2) Firm mass in the anterior part of the right for 6 months. On examination it reveals that side of the floor of the mouth. swelling was hard, non-tender, local On neck examination, the patient showed temperature not raised and bimanually diffuse swelling over the left submandibular palpable. Neck radiograms (fig. 5). and region measuring 7× 6× 5cm, with normal ultrasonography revealed a sialolith of 54 mm overlying skin. There were no signs of sinus, in length and 25 mm in diameter at its widest fistula, or ulceration in the affected region. The portion. Blood pressure and pulse rate were swelling was warm and tender on palpation within normal limits. Chest radiograms, with a firm consistency. No nodular or matting electrocardiography, total blood count, urine characteristics were noted. sediment, liver and kidney function test were Intraoral examination showed hard, also normal. Under general anaesthesia, a inflammation, induration, swelling of the right surgical resection of the left submandibular Wharton’s duct (fig. 1). The left submandibular gland was performed (fig. 6&7). Post- gland was tender on bimanual palpation. operatory course was good and the patient was discharged after two days. No injury to Radiologically patient was evaluated which lingual or hypoglossal nerve occurred. includes, lower occlusal radiograph and X- ray Pathology neck AP and Lateral view which showed the mass to be radiopaque and extending back beyond the lower right first permanent molar Microscopic evaluation of the gland revealed a (fig. 2&3). A diagnosis of right submandibular chronic sialadenitis with infiltration of duct calculus was made and sialolithotomy was lymphocytes in the stroma and destruction of planned under local anaesthesia, after giving the acini and of the main duct 5 . local anaesthesia upward and medial pressure Discussion was applied to the submandibular gland, and an incision was placed directly over the sialolith to expose it, multiple stone were Although large sialoliths have been reported in removed measuring to be 70mm long when the body of salivary glands, they have been kept together to greatest length (fig. 4). The rarely been reported in the salivary ducts. larger portion of the sialolith which was of Messerly removed a 51 mm long calculus that 20mm, delivered out first with the sinus occupied the entire length of Stenson’s duct in forceps then thorough exploration and 66-year-old man. Brusati and Fiamminghi continuous massaging of the submandibular removed a sialolith from the left gland with upward and medial pressure was submandibular duct of a 55- year-old man applied to mobilize the distal portions of the measuring 27x31 mm. More recently Leung et stone with the sinus forceps. Wharton’s duct al. removed a sialolith 14x9 mm from the right stoma kept open to facilitate drainage of left submandibular duct 10 . The sialolith removed in fragments of stone. Postoperatively patient our first and second case were far bigger was relieved of pain and swelling regressed. measuring 70x11mm and 54x25mm. The patient was reviewed one weeks post Aetiology operatively to check salivary function of the gland. On review the right submandibular gland was palpable but clear saliva could be The exact aetiology and pathogenesis of expressed from the Wharton’s d uct stoma on salivary calculi is largely unknown. Genesis of massage. calculi lies in the relative stagnation of calcium rich saliva. They are thought to occur as a result