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CASE REPORT
Year : 2015  |  Volume : 6  |  Issue : 1  |  Page : 69-72

Giant sialolith in the Wharton's duct


1 Department of Oral Medicine and Radiology, Rural Dental College, Loni, Maharashtra, India
2 Department of Prosthodontics, Rural Dental College, Loni, Maharashtra, India

Date of Web Publication19-Jan-2015

Correspondence Address:
Vikrant Omprakash Kasat
Department of Oral Medicine and Radiology, Rural Dental College, Loni - 413 736, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-433X.149599

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  Abstract 

Sialolithiasis is the most common salivary gland disease which has predilection for males and is often seen in adults. Majority of sialolith occur in the submandibular gland and its duct. Giant salivary calculi measure >1.5 cm in size and are uncommon in the salivary ducts. The purpose of this article is to report a case of asymptomatic giant sialolith in the Wharton's duct of a 55-year-old female, which was detected when patient had gone for an Ear Nose Throat examination. Furthermore, literature in English language on "giant sialolith in Wharton's duct" is reviewed since 1990.

Keywords: Giant, sialolith, submandibular duct, Wharton′s duct


How to cite this article:
Kasat VO, Farooqui AA, Ladda R. Giant sialolith in the Wharton's duct. SRM J Res Dent Sci 2015;6:69-72

How to cite this URL:
Kasat VO, Farooqui AA, Ladda R. Giant sialolith in the Wharton's duct. SRM J Res Dent Sci [serial online] 2015 [cited 2023 Feb 8];6:69-72. Available from: https://www.srmjrds.in/text.asp?2015/6/1/69/149599


  Introduction Top


Sialolithiasis is the most common pathology of the salivary glands. [1],[2] It has an incidence of about 0.012% in the adult population [3],[4] and affects males twice as much as females. [5],[6] It may be seen at any age, but the peak incidence is observed in 4 th , 5 th and 6 th decades. [7] Submandibular gland is the most commonly affected salivary gland as it accounts for more than 80-95% of cases. [1],[2],[5] Sialolithiasis typically presents as a painful swelling of the affected gland during mealtimes, because the stone, usually, does not block the flow of saliva completely. [8] Usually, sialolith are <1 cm in size [1] and if their size exceeds 1.5 cm, they are considered as giant sialolith. [3],[9]

Giant sialolith were considered rare in the duct of salivary glands as more cases were observed in the glandular parenchyma, [3] but as the number of journals is increasing, more cases of ductal sialolith are being reported. The purpose of this article is to report another case of giant sialolith in the Wharton's duct and to review the related literature.

Search strategy for review of the literature

A search of "PubMed" and "Google scholar" was made with the keywords "giant sialolith in the Wharton's duct," "megalith in the wharton's duct," "salivary duct calculus." It was supplemented with a hand search to identify related published articles in dental journals. For a review, articles published from 1990 onwards in English language were selected. Our search revealed that only 37 cases of giant sialolith in the Wharton's duct are reported in last 24 years [Table 1].
Table 1: Summary of case reports of giant sialolith in the Wharton's duct in chronological order

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  Case report Top


A 55-year-old female was referred from Ear Nose Throat Department to the Department of Oral Medicine and Radiology, for the finding of swelling in the floor of the mouth on the left side. Detailed history revealed that the patient had sore throat since 2-3 days and had gone to an Ear Nose Throat surgeon who found a swelling in the mouth and referred her for radiograph to our department. Intraoral examination revealed a well-defined round swelling of approximately 2 cm × 1 cm in size in the floor of the mouth in relation to lower left second premolar and first molar. Overlying mucosa was normal in color. It was firm in consistency and tender on palpation [Figure 1]. A provisional diagnosis of sialolith in the left submandibular gland duct was made.
Figure 1: Intraoral photograph showing swelling in the floor of the mouth on left side

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Radiographic evaluation included cross-sectional mandibular occlusal view [Figure 2] and orthopantomogram [Figure 3], which revealed a large well defined oval homogenous radiopacity in the floor of the mouth on left side in relation to lower left second premolar and first molar. Sialolith was enucleated under local anesthesia. The incision was taken in the antero-posterior direction to the required length and blunt dissection was done to enucleate sialolith in toto which measured 2 cm × 1 cm in size [Figure 4]. Postoperative healing was uneventful.
Figure 2: Mandibular occlusal view revealing homogenous radiopacity in the floor of the mouth on left side

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Figure 3: Orthopantomogram showing a well defined radiopacity in relation to lower left second premolar and first molar

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Figure 4: Excised giant sialolith, measuring 20 mm × 10 mm

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  Discussion Top


Salivary calculi or sialoliths form more commonly in the submandibular gland compared to other glands because its duct is wider, longer, and tortuous, its punctum is smaller, [25] saliva flows against gravity, salivary secretion is more alkaline and its saliva has higher content of mucin, proteins, calcium as well as phosphates. [1],[14],[19] Commonly sialoliths are thought to occur as a result of deposition of the tricalcic phosphate salts around a nidus that may be an altered salivary mucin, desquamated epithelial cells or bacteria. [3],[27]

The age in the cases reviewed ranged from 22 [25] to 75 [21] years with an average of 50.2 years. Among the cases reviewed, majority were seen (32/37) in patients over the age of 40 years. Among the 37 cases reviewed, the incidence is higher in men (n = 28) compared with women (n = 9) with male to female ratio of 3.1:1. Our patient was a 55-year-old female. The giant sialoliths in the reported cases varied in size from 15 mm [9] to 72 mm [5] . The sialolith presented by rai [5] is the largest ever reported calculus in Wharton's duct (72 mm). Weight of the sialolith varied from as light as 0.59 g [26] to as heavy as 45.8 g. [5] In reported cases it is not made clear whether mentioned weight is dry or wet weight except in the case of akimoto [13] who mentions it as dry weight. In our case, the calculus was 20 mm × 10 mm in length and width and 1.55 g in dry weight.

Duration of the symptoms was reported in 20 cases that ranged from 2 days [17] to 22 years. [22] In 4 cases, patient was unaware about any pathology present in the mouth. It is believed that a calculus may enlarge at the rate of approximately 1-1.5 mm/year. [8],[28] Thus, it is possible to explain the long duration of symptoms in few cases. In the reviewed cases, sialolith occurred on the left side in 22 cases whereas in 11 cases it occurred on the right side. In 4 cases, side was not mentioned. Thus, it appears that the giant sialolith has affinity for the left side. Pain and swelling were the most common symptom in the reviewed cases. The severity of symptoms depends on the degree of obstruction and residual duct patency. [30] In the present case patients left side was affected, but patient was asymptomatic and was unaware about the swelling present in the mouth.

As giant sialoliths are mostly radiopaque, panoramic and occlusal views are enough to detect giant calculi in Wharton's duct [3],[11],[12] as in the present case. If not removed giant calculi may cause various complications like sialo-oral fistula, [3],[10],[13],[15],[16],[20],[29] sialo-cutaneous fistula, [6] atrophy and fibrosis of the gland. [4],[17] The differential diagnosis of sialolith includes calcified lymph node, embedded tooth, foreign body, phlebolith, and myositis ossificans. [3],[11] In a case described by Gupta et al., [27] giant sialolith resembled canine tooth.

The treatment objective for giant sialolith is restoration of normal salivary secretion. [23],[27] Newer minimally invasive treatment modalities such as shock-wave lithotripsy, sialoendoscopy, interventional radiology are effective alternatives to conventional surgical excision for smaller sialolith (<7 mm). [3] However, giant sialoliths are best managed by transoral sialolithotomy, [18],[24] as in the present case.


  Conclusion Top


A case of asymptomatic giant sialolith in a 55-year-old female is presented. Even in asymptomatic cases of giant sialolith, patient should be convinced for surgical intervention to prevent further complications.

 
  References Top

1.
Ledesma-Montes C, Garcés-Ortíz M, Salcido-García JF, Hernández-Flores F, Hernández-Guerrero JC. Giant sialolith: Case report and review of the literature. J Oral Maxillofac Surg 2007;65:128-30.  Back to cited text no. 1
    
2.
Silva-Junior GO, Picciani BL, Andrade VM, Ramos RT, Cantisano MH. Asymptomatic large sialolith of Wharton′s duct: A case report. J Stomatol Occlusion Med 2010;3:208-10.  Back to cited text no. 2
    
3.
Saluja H, Kasat VO, Mahindra U. Giant sialolith in the Wharton′s duct causing sialo-oral fistula: A case report and review of literature. J Orofac Sci 2012;4:137-42.  Back to cited text no. 3
  Medknow Journal  
4.
Siddiqui SJ. Sialolithiasis: An unusually large submandibular salivary stone. Br Dent J 2002;193:89-91.  Back to cited text no. 4
    
5.
Rai M, Burman R. Giant submandibular sialolith of remarkable size in the comma area of Wharton′s duct: A case report. J Oral Maxillofac Surg 2009;67:1329-32.  Back to cited text no. 5
    
6.
Paul D, Chauhan SR. Salivary megalith with a sialo-cutaneous and a sialo-oral fistula: A case report. J Laryngol Otol 1995;109:767-9.  Back to cited text no. 6
    
7.
Lustmann J, Regev E, Melamed Y. Sialolithiasis. A survey on 245 patients and a review of the literature. Int J Oral Maxillofac Surg 1990;19:135-8.  Back to cited text no. 7
    
8.
Alkurt MT, Peker I. Unusually large submandibular sialoliths: Report of two cases. Eur J Dent 2009;3:135-9.  Back to cited text no. 8
    
9.
Oteri G, Procopio RM, Cicciù M. Giant salivary gland calculi (GSGC): Report of two cases. Open Dent J 2011;5:90-5.  Back to cited text no. 9
    
10.
Hubar JS, Guggenheimer J, Evan M. Megalith. Oral Surg Oral Med Oral Pathol 1990;70:245.  Back to cited text no. 10
    
11.
Gonçalves M, Hochuli-Vieira E, Lugão CE, Monnazzi MS, Gonçalves A. Sialolith of unusual size and shape. Dentomaxillofac Radiol 2002;31:209-10.  Back to cited text no. 11
    
12.
Bodner L. Giant salivary gland calculi: Diagnostic imaging and surgical management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:320-3.  Back to cited text no. 12
    
13.
Akimoto Y, Sakae T, Toyoda C, Ono M, Hasegawa K, Tanaka S, et al. An unusually large submandibular salivary calculus: Case report and structural analysis. Int J Oral Med Sci 2004;2:50-3.  Back to cited text no. 13
    
14.
Chan EK, Patel ND. Giant calculus of the submandibular salivary duct. Ear Nose Throat J 2006;85:306, 308.  Back to cited text no. 14
    
15.
Patil S, Sharma S, Prasad LK. Submandibular megalith with erosion of the floor of mouth - A rare case report. World Article in Ear Nose and Throat 2009;2.  Back to cited text no. 15
    
16.
El Gehani R, Krishnan B, Shehoumi MI. Submandibular giant sialoliths: Report of two cases and review of the literature. Ear Nose Throat J 2010;89:E1-4.  Back to cited text no. 16
    
17.
García-Consuegra L, Rosado P, Gallego L, Junquera L. Unilateral absence of submandibular gland secondary to stones. Aplasia versus early atrophy. Med Oral Patol Oral Cir Bucal 2010;15:e752-4.  Back to cited text no. 17
    
18.
Boffano P, Gallesio C. Surgical treatment of a giant sialolith of the Wharton duct. J Craniofac Surg 2010;21:134-5.  Back to cited text no. 18
    
19.
Abdeen BE, Khen MA. An unusual large submandibular gland calculus: A case report. Smile Dent J 2010;5:14-7.  Back to cited text no. 19
    
20.
Shetty BN, Sharma P. Unusual case of a projecting intraoral giant sialolith. Indian J Surg 2010;72:155-7.  Back to cited text no. 20
    
21.
Cottrell D, Courtney M, Bhatia I, Gallagher G, Sundararajan D. Intraoral removal of a giant submandibular sialolith obstructing Wharton′s duct: A case report. J Mass Dent Soc 2011;60:14-6.  Back to cited text no. 21
    
22.
Omal P, Mathew G. Giant sialolith in the Wharton′s duct - A case report. J Indian Dent Assoc 2011;5:649-51.  Back to cited text no. 22
    
23.
Leite TC, Blei V, de Oliveira DP, Robaina TF, Janini ME, Meirelles V Jr. Giant asymptomatic sialolithiasis. Int J Oral Med Sci 2011;10:175-8.  Back to cited text no. 23
    
24.
Iqbal A, Gupta AK, Natu SS, Gupta AK. Unusually large sialolith of Wharton′s duct. Ann Maxillofac Surg 2012;2:70-3.  Back to cited text no. 24
[PUBMED]  Medknow Journal  
25.
Singh A, Kalia V, Sekhon J. An anterior submandibular calculi: An anatomical appraisal. Novel Science International Journal of Medical Science 2012;1:123-6.  Back to cited text no. 25
    
26.
Dalal S, Jain S, Agarwal S, Vyas N. Surgical management of an unusually large sialolith of the Wharton′s duct: A case report. King Saud Univ J Dent Sci 2013;4:33-5.  Back to cited text no. 26
    
27.
Gupta A, Rattan D, Gupta R. Giant sialoliths of submandibular gland duct: Report of two cases with unusual shape. Contemp Clin Dent 2013;4:78-80.  Back to cited text no. 27
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28.
Tyagi S, Yadav S, Kumar P, Bhandari PP. Large intraductal sialolith in Wharton′s duct. SRM J Res Dent Sci 2013;4:43-5.  Back to cited text no. 28
  Medknow Journal  
29.
Nemade SV, Rokade VV, Pathak NA. A giant sialolith with perforation of the floor of mouth. Otolaryngol Online J 2013;3:171-84.  Back to cited text no. 29
    
30.
Krishnan AR, Raj SV, Sooraj S, Rahul R, Kamal SS, Deepa MS. Giant submandibular sialolith. Kerala Dent J 2014;37:37-9.  Back to cited text no. 30
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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