|Year : 2015 | Volume
| Issue : 1 | Page : 69-72
Giant sialolith in the Wharton's duct
Vikrant Omprakash Kasat1, Anjum Ara Farooqui1, Ruchi Ladda2
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 Publication||19-Jan-2015|
Vikrant Omprakash Kasat
Department of Oral Medicine and Radiology, Rural Dental College, Loni - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
Sialolithiasis is the most common pathology of the salivary glands. , It has an incidence of about 0.012% in the adult population , and affects males twice as much as females. , It may be seen at any age, but the peak incidence is observed in 4 th , 5 th and 6 th decades.  Submandibular gland is the most commonly affected salivary gland as it accounts for more than 80-95% of cases. ,, 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.  Usually, sialolith are <1 cm in size  and if their size exceeds 1.5 cm, they are considered as giant sialolith. ,
Giant sialolith were considered rare in the duct of salivary glands as more cases were observed in the glandular parenchyma,  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|| |
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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| Discussion|| |
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,  saliva flows against gravity, salivary secretion is more alkaline and its saliva has higher content of mucin, proteins, calcium as well as phosphates. ,, 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. ,
The age in the cases reviewed ranged from 22  to 75  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  to 72 mm  . The sialolith presented by rai  is the largest ever reported calculus in Wharton's duct (72 mm). Weight of the sialolith varied from as light as 0.59 g  to as heavy as 45.8 g.  In reported cases it is not made clear whether mentioned weight is dry or wet weight except in the case of akimoto  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  to 22 years.  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. , 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.  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 ,, as in the present case. If not removed giant calculi may cause various complications like sialo-oral fistula, ,,,,,, sialo-cutaneous fistula,  atrophy and fibrosis of the gland. , The differential diagnosis of sialolith includes calcified lymph node, embedded tooth, foreign body, phlebolith, and myositis ossificans. , In a case described by Gupta et al.,  giant sialolith resembled canine tooth.
The treatment objective for giant sialolith is restoration of normal salivary secretion. , 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).  However, giant sialoliths are best managed by transoral sialolithotomy, , as in the present case.
| Conclusion|| |
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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]