Rare Giant Submandibular Gland Calculus: A Case Report

Abstract

Salivary gland calculus / Sialolithiasis is the most common disease of the salivary glands. Sialolithiasis is most commonly found in the submandibular gland and it's duct (Wharton's duct). Giant salivary gland stones measuring over 3cm are extremely rare with only scanty reported cases 1 . This report describes the case of a patient who had a painless very rare giant Submandibular sialolith visible per orally on the floor of mouth. A 5× 2 cm sized stone was excised. INTRODUCTION:Sialolithiasis (also termed salivary calculi, or salivary stones), is a condition where a calcified mass forms within a salivary gland. The term is derived from the Greek words sialon (saliva) and lithos (stone), and the Latin -iasis meaning "process" or "morbid condition".Sialolithiasis is the most common disease of salivary glands 1 . Stones or calculi can be found in all major and minor salivary glands and their ducts. More than 80 % of the calculi are found in Submandibular gland and its duct (more common) 2 . Parotid gland accounts for 10% of cases. Remaining cases involve Sublingual and minor salivary glands 2 .Submandibular calculi are most commonly seen in young and middle aged adults with equal affection of both sexes 3 . Longer and upward course of the submandibular duct, non-dependent drainage, high calcium and mucin content, more viscid secretion are the factors which favour the formation of submandibular duct stones 3 . Bilateral or multiple gland sialolithiasis occurs in less than 3% of cases 4 .Commonly sialoliths measure from 1mm to less than 1cm. Giant salivary gland stones (GSGS) are those stones measuring over 1.5cm and have been rarely reported. GSGS measuring over 3cm are extremely rare with only scanty reported cases 5 . The aim of this case report is to highlight a case of a very rare giant sialolith.

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

“…[22] There were several reports on the removal of giant sialoliths intra-orally, but all of them had calculi described within the distal portion of the Wharton's duct. Among the case reports were from Soares, et al [3,20,29,[30][31][32][33] However, there was one case reported of an intraoral removal of giant sialolith (25 mm) located at the proximal part of Wharton's duct but it was not mentioned whether it was extending into the intra-glandular ductal at the hilum and causing obstruction as in our case. [23] A study by Park, et al (2012) to identify a surgical landmark for a suitable approach to remove proximal Wharton's duct and hilum sialoliths, found that all of 74 patients had successfully underwent intraoral removal of the sialoliths with a mean size of 8 mm, which was below the size of giant sialolith.…”

“…For calculi located exclusively in the duct and near the papillae, intraoral approach by using minimally invasive treatment through the manipulation of lacrimal probes and dilators to open the duct orifice in order to milk out the calculus are adequate. [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.…”

“…[17,25] 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.…”

Salivary Megaliths: A Literature Review of Giant Salivary Sialoliths Larger than 30 mm

“…Extra-oral methods are used for intragonadal sialoliths and those in the glandular umbilical cavity. Note that extra-oral access has a risk of injury to the mandibular marginal nerve [34,35]. Salivary megaliths may be split into smaller pieces using an additional shockwave lithotripsy or an endoscopic intracorporeal lithotripsy wave.…”