Giant Submandibular Calculus Eroding Oral Cavity Mucosa

Abstract

Sialolithiasis is the formation of calculi or sialoliths in the salivary gland. It is the most common benign condition of the salivary gland. Sialolithiasis can occur in all salivary glands. The submandibular gland is most commonly affected followed by the parotid gland. Calculi commonly measure less than 10 mm. Calculi of more than 15 mm are termed giant salivary gland calculi and are infrequently reported in the literature. Here, we report a case of unusually large submandibular gland calculus of 5 cm in greatest dimension which caused erosion of the oral cavity.

Transcervical Removal of a Rare Giant Proximal Wharton’s Duct Sialolith and Submandibular Gland

“…Salivary stasis, ductal inflammation, and injury promote aggregation of mineralized debris to form nidus, which ultimately initiates the formation of sialolith. [13] A number of factors are believed to be responsible in the development and growth of salivary stones in submandibular gland tissues: Wharton's duct is wider and longer than Stenson's duct, the direction of salivary flow in the submandibular duct system is in opposition to that of the force of gravity, submandibular saliva is more alkaline compared with that of the parotids, the submandibular gland secretion comprises a higher amount of mucin proteins, whereas the parotid gland secretion is totally serous, and calcium and phosphate content in submandibular saliva are greater than that in other glands. [14] Based on 120 submandibular gland sialendoscopy studies, Marchal, et al (2001), observed the presence of a sphincter system in the first 3 cm of Wharton's duct in 90% of the cases and proposed that variation of such sphincter-like mechanism within the salivary ducts could be responsible for easier retrograde movement of oral materials.…”

“…Some will experience xerostomia and infrequently the sensation of a gritty, sand-like foreign body in their mouth. [13] The exact etiology of sialolithiasis is unclear. Salivary stasis, ductal inflammation, and injury promote aggregation of mineralized debris to form nidus, which ultimately initiates the formation of sialolith.…”

“…[17,25] Majority of symptomatic intra-glandular sialoliths or larger sialoliths embedded in the gland which is inaccessible via a tran-soral approach entail surgical excision of the total gland. [10,13,17,20] Generally, most of the sialodenectomies are performed transcervically, but it has some disadvantages; hence, minimally invasive techniques are becoming increasingly significant especially for smaller stones. [26] In particular, intra-oral calculi removal has advantages, including patient tolerability and acceptance, a less surgery time, and the ability to be performed under both local and general anesthesia.…”

“…[4] Normal saliva comprises plentiful hydroxyapatite. [13] Sialoliths consist primarily of calcium phosphate, carbonate hydroxyapatite in combination with an organic matrix of glycoproteins, and mucopolysaccharides. Small amounts of other salts such as magnesium, potassium, and ammonium are also involved in calculus formation.…”

“…[17,20,21] Marsupialization via intraoral considered to be the best surgical option for calculi located close to the orifice of the duct. [13] The invasive, surgical approach involves an incision along the longitudinal axis of Wharton's duct directly onto the stone. [17,21] In regards to giant sialoliths, transoral-sialolithotomy with sialodochoplasty or sialadenectomy remains the mainstay of management.…”