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| CASE REPORT |
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| Year : 2013 | Volume
: 4
| Issue : 1 | Page : 43-45 |
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Large intraductal sialolith in Wharton's duct
Shallu Tyagi1, Suresh Yadav2, Prince Kumar3, Poonam Preet Bhandari1
1 Department of Pedodontics, Kalka Dental College and Hospital, Meerut, India
2 Department of Oral and Maxillofacial Surgery, Kalka Dental College and Hospital, Meerut, India
3 Department of Prosthodontics, Shree Bankey Bihari Dental College and Research Centre, Ghaziabad, Uttar Pradesh, India
| Date of Web Publication | 22-Aug-2013 |
Correspondence Address:
Prince Kumar
Department of Prosthodontics, Shree Bankey Bihari Dental College and Research Centre, Masuri, N.H. 24, Ghaziabad, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0976-433X.116835
Sialolithiasis is one of the most common disease of salivary glands and it has been estimated that it affects 12 in 1000 of the adult population. More than 80% occur in the sub mandibular gland or its duct, 6% in the parotid gland and 2% in the sublingual gland or minor salivary glands and are a common cause of acute and chronic infections. Clinically, they are round or ovoid, rough or smooth and of a yellowish color. They consist of mainly calcium phosphate with smaller amounts of carbonates in the form of hydroxyapatite, with smaller amounts of magnesium, potassium, and ammonia. Sub mandibular stones are 82% inorganic and 18% organic material whereas parotid stones are composed of 49% inorganic and 51% organic material. The organic material is composed of various carbohydrates and amino acids. Bacterial elements have not been identified at the core of a sialolith and this report describes the case of a patient who had an unusual large submandibular gland sialolith (calculus) completely obstructing the sub mandibular gland duct. Patients with sialolithiasis require definitive surgical treatment in most cases, which results in an excellent prognosis. Keywords: Salivary gland, sialolithiasis, Wharton′s duct
How to cite this article:
Tyagi S, Yadav S, Kumar P, Bhandari PP. Large intraductal sialolith in Wharton's duct. SRM J Res Dent Sci 2013;4:43-5 |
| Introduction | |  |
Sialolithiasis is the most common disease of the salivary glands in middle-aged patients. Though rare, it can also occur in young children. Clinical features develop in consequence to obstruction of salivary flow. They may be presented mainly at meal time as pain and swelling distal to the region obstructed by stone. [1]
Clinical suspicion should lead to further imaging-based diagnostic measures; ultrasonography (US) and two-dimensional (2D) radiography are commonly used in such assessments. Irregular findings sometimes justify sialendoscopy, sialography, magnetic resonance imaging (MRI), or computed tomography (CT). Each of these imaging modalities has its unique diagnosis profile: US is the least invasive method. Failure has been reported in cases of small semi-calcified stones. [2],[3] US sensitivity for salivary stone detection is reported to be 75.0%, Conventional 2D radiography sensitivity rates are reported to be about 60%. For MRI sialography, a sensitivity of 69% has been reported with the potential to increase the sensitivity to 100% if MRI sialography is combined with control radiographs. [4] Three-dimensional (3D) medical CT can successfully display even the smallest or semi-calcified calculi, but at the expense of high-radiation doses to patients. [5] Despite the advantages of 3D medical CT or MRI evaluations, US and 2D radiography are routinely used owing to cost-effectiveness, availability, and lower radiation dosages.
Patients with salivary calculi are normally managed by removal of the calculus or, if necessary, the affected gland. If it is left untreated, a stone may migrate into the adjacent tissues. [6] These are also known to perforate the floor of mouth by ulcerating the duct 'which result in fistula in skin by causing suppurative infection. Untreated calculi can cause obstruction and glandular atrophy, and then may exfoliate through the floor of the mouth. Karengera et al. has reported a case of cutaneous exfoliation of a salivary gland stone. [7]
Salivary calculi are usually small and measure from 1 mm to less than 10 mm and often measure up to 15 mm. Giant sialoliths are rare and defined as the size of 35 mm or larger. The majority of sialoliths are round to oval in shape and shows variety in number and size. Their color ranges from white to brown and they have nodular surfaces with prominences. These have been reported in salivary gland parenchyma and rarely in salivary gland duct. These are believed to enlarge at the rate of 1-1.5 mm/year. The enlargement occurs due to an extra deposition of minerals, duct lining cells or bacteria. [8]
| Case Report | | |
A 69-year-old male reported to the Department of Oral and Maxillofacial Surgery with chief complaint of dull, intermittent aching pain since 2-3 months. The phenomenon occurred 7-8 times per week, during meals. He also complained of dry mouth and swelling on the left side of the neck occurring with meals. Medical history was unremarkable. On extra oral examination, there was no palpable mass found. On examination, bimanual palpation of the swollen area corresponding to the anatomic location of the left sub mandibular salivary gland duct further indicated that the mass was mobile, firm, and tender. Other intraoral findings included generalized attrition and missing maxillary posterior teeth. Orthopantomogram (OPG) revealed an oval shaped radiopacity extending from pre-molar region to the body of mandible on left side [Figure 1]. On clinical correlation, a diagnosis of intra-ductal sialolithiasis was made. After explaining, to the patient the diagnosis and the procedure's risks and benefits, informed consent was obtained and signed by the patient. | Figure 1: Panorex view showing radiopacity in left mandibular body region superimposing over the premolar region
Click here to view |
Under local anesthesia, the calculus was excised via incision in the floor of the mouth, directly over the palpable mass. The calculus/mass obtained was cylindrical in shape, hard in consistency, about 35 mm in length and around 10 mm across [Figure 2]. The yellowish calculus had a rough, irregular surface and the gland was not resected. Specimen was sent for histopathological examination, which on decalcification revealed lamellated appearance with alternating eosinophilic and basophilic zones disposed concentrically in shape of globular calcified areas was predominant being noted. This pattern was associated with a hetrogeneous mass. | Figure 2: Specimen after being excised from the duct. Note the prominences and granulations on the surface
Click here to view |
| Discussion | | |
Sialolithiasis is the formation of calcific concretions in the salivary duct or glands. Male predominance has been reported in literature and the mean age varies from third to seventh decade of life. Al Masri reported that in comparison to other salivary gland, sub mandibular gland is rich in viscous secretion of high alkalinity and a further difference of length; diameter and cranial direction of excretory duct predispose the gland for development of sialolith. [1]
Other contributing factors include presence of mucin proteins and high-content of calcium and phosphate in salivary secretion of the gland. Several local, chemical or mechanical factors, in precipitation of the mineral salts are involved. Montes and Oritz have suggested that infection, inflammation, salivary stagnation, introduction of foreign bodies and presence of desquamated epithelial cells seems to be the initial events for formation of a nidus that later will be the site for precipitation of mineral salts present in salivary secretion. [9]
Salivary calculus grows up to the rate that has been estimated at approximately 1-1.5 mm/year and range in size from 0.1 mm to 30 mm. The most common site is sub mandibular gland where 80-90% of calculi are found. Makidissi has reported a calculus growth rate of up to 3.5 mm a year and it can be attributed to presence of any previous stone or presence of large sac in the duct after its removal. [10]
Untreated sialoliths might lead to infections. This occurs when pathogenic bacteria ascend from the mouth, reaching the affected gland or the saliva stagnating in the dilated ducts. [9],[11] It might cause damage of the parenchyma and produce a suppurative process, associated with a fistula and pus drainage via mucosa or skin. [6],[12]
Each of these imaging modalities has its unique diagnosis profile: US is the least invasive method. Failure has been reported in cases of small semi-calcified stones. [11] US sensitivity for salivary stone detection is reported to be 75.0%, and for accompanying inflammatory reactions in salivary glands the sensitivity is reported to be 77.4%. [13] Conventional 2D radiography is failure-susceptible for small or less-calcified calculi especially, if superimposed by well-calcified bone, and 10-30% of salivary stones are categorized as radiolucent. [12] Sensitivity rates are reported to be about 60%. [13],[14],[15] By injecting radiopaque dye into salivary glands orifice sialography can display radiolucent calculi as filling defects. Application of sialography is restricted and contraindicated during acutely infectious manifestations. [16] MRI is reported to be a valuable additional diagnostic method in difficult cases, or when further soft-tissue diagnosis is necessary. [13] For MRI sialography, a sensitivity of 69% has been reported, with the potential to increase the sensitivity to 100% if MRI sialography is combined with control radiographs. [4]
The treatment objective of giant sialolith, as for standard-sized stones, is restoration of normal salivary secretion. [11] Sialography was used in past mainly for diagnosis in patients suffering from obstructive pathology. It is routinely carried out for the affected gland after acute phase. Sialoendoscopy enables the surgeon to see different aspect of the glands by showing the intra ductal and intra glandular microanatomy. It can also be removed via a trans-oral sialolithotomy, to avoid the morbidity associated with sialadenectomy. The clinician should evaluate carefully the painful or painless swelling in sub mandibular area. In most cases, diagnosis is made following acute obstructive or inflammatory episode, which must be treated appropriately.
| Conclusion | | |
This case highlights a rare case of large calculus, which can be avoided by early diagnosis and proper treatment. Patients should be educated regarding the mechanism of their underlying pathology and methods of maintaining control over them by emphasizing the value of hydration and excellent oral hygiene, which lessens the severity of the attacks and prevents dental complications. Once the diagnosis of a salivary gland stone is established, attempts at removal by minimally invasive techniques should be considered.
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[Figure 1], [Figure 2]
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