Unusual giant sialolith of Wharton's duct

Abstract

Salivary gland calculi account for the most common disease of the salivary glands. Most of the salivary calculi are small in size. Some calculi that reach several centimeters are reported as megaliths or giant calculi in the literature. They may occur in any of the salivary gland ducts but are most common in Wharton's duct and in the submandibular gland. This report presents clinical and radiographical sign of an unusually large sialolith. A patient came with pain in the floor of mouth. There was a swelling on floor of mouth on the left side. Radiographical examination revealed large irregular radio-opaque mass superimposed on left lateral incisor to molar areas. This case report describes a patient presenting with an unusually large submandibular gland duct sialolith, the subsequent patient management, the etiology, diagnosis, and its treatment.

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.…”

3D Reconstruction and Prediction of Sialolith Surgery

“…The aetiology of sialolithiasis is still unknown, but some authors believe that persistent changes in saliva flow along with an increased amount of mucus facilitates the precipitation of amorphous phosphate tricalcium [2, 3, 5, 8], which becomes crystallised and transforms into hydroxyapatite. From this matrix, there is an apposition of several substances which also become calcified and form the sialolith [2, 3, 5, 6, 8].…”

“…In general, they are asymptomatic, presenting a slight increase in glandular volume during salivary stimulation, which causes a mild sensation of discomfort [3, 4]. …”

“…Nevertheless, aetiological factors may be related to the salivary content [2, 5], including other factors such as trauma to salivary duct or gland and precipitation of salts linked to certain organic substances. There is also a theory in the literature stating that a retrograde infection might explain the sialolithiasis as food residues, substances, or bacteria which can migrate into the salivary ducts, becoming then a niche for more calcification [3–6]. …”

“…However, depending on the location of sialolith (e.g., mainly in the duct of the submandibular gland), occlusal radiograph can be used for its visualisation [3, 8] if it is located in the glandular parenchyma; otherwise, other imaging examinations allow a better visualisation. In this latter case, complete resection of the gland is necessary because there is a high rate of relapse and the calcified mass cannot pass through the duct, which requires a lateral transcervical approach for removal of the submandibular gland [2–4, 8, 9].…”