Management Of Anterior Submandibular Sialolithiasis

Management Of Anterior Submandibular Sialolithiasis

Describe the etiology, clinical features, and treatment of submandibular sialolithiasis. 

Answer. Sialolithiasis is the formation of hardened intraluminal deposits in ductal system of salivary gland which obstructs the normal flow of saliva.

Submandibular Sialolithiasis Etiology

The exact cause for sialolith or calculus formation is not clear but factors which contribute to its formation are:

• Stagnation of saliva
• Focus for sialolith formation resulting from ductal epithelial inflmmation and injury.
• Poorly understood biological factors favoring precipitation of calcium salts.

“Early Signs Of Submandibular Salivary Calculus”

Hilus is the most common site for the formation of sialolith but it can arise anywhere throughout the ductal system.

80% of all salivary duct stones develop in the submandibular or Warthin’s duct.

“Best Ways To Prevent Salivary Calculus”

Predisposition of sialolith formation for the submandibular gland can be due to:

• Composition of secretion of sub mandibular salivary gland is more alkaline and viscous.
• Submandibular gland consists of higher concentration of calcium and phosphorus ions as compared to other major salivary glands.
• Both submandibular gland and duct are placed in such an anatomically dependent position that the flow of saliva is against gravity which gives more chances for stasis of saliva inside the ducts.
• Stagnation of secretions in Warthin’s duct can also due to angulation of duct as it courses around the mylohyoid muscle and the vertical orientation of the distal duct segment.

Submandibular Sialolithiasis Clinical Features

• It is usually seen in patients in the 5th to 8th decade of life.
• Recurrent swelling of the gland region is seen at the meal time.
• Recurrent episodes of acute, subacute or suppurative sialadenitis are present.
• Swelling is sometimes seen as hard lump present in the flor of the mouth or cheek.
• Submandibular salivary gland becomes tense and tender.
• Swelling and tenderness subside only to recur again during meal time.
• Large submandibular calculi can be seen as a swelling in the flor of the mouth.
• Stone may be palpable during bimanual palpation and may be movable up and down the duct.
• As in chronic infection and obstruction, the gland undergoes atrophy rarely, becomes indurated and when operated it is seen to be adherent to adjacent structures.

“Is Submandibular Salivary Calculus Painful”

Submandibular Sialolithiasis Treatment

Treatment is surgical.

Removal Of Submandibular Calculi (transoral sialolithotomy)

• Place the patient in sittng position and give local anesthesia.
• Locate the stone accurately by using radiographs and palpation.
• Pass a suture behind the stone as well as below the duct to prevent stone from sliding backwards during removal.
• Retract the tongue for proper visualization.
• Palpate submandibular gland extraorally in submandibular region and is pushed upwards toward floor of mouth to fi intraoral tissues under tension. During this take care of lingual nerve and sublingual gland.
• If the sialolith is present posteriorly, incision should be placed slightly medially to avoid injury to the lingual nerve.
• Place a superfiial incision through mucosa alone and give blunt dissection to reach the duct for preventing injury to the lingual nerve.

“Risk Factors For Developing Salivary Stones”

• If stone is more anteriorly placed, incision is given medial to plica sublingualis or else there are chances of injury to sublingual gland.
• Duct should be located at place where stone is lodged. As duct is located, a longitudinal incision is given directly over the duct where stone is located.
• Transverse incision should not be given as it retracts and gets divided completely and a salivary fitula may be formed.
• Incision given should reveal the stone and is of suffient length to be removed easily. Stone can usually be removed easily with a forceps or a larger stone may need to be crushed into smaller pieces and removed.
• A probe is then passed from the caruncle to the region of stone to ensure patency of the duct in the anterior region.
• Incision on the duct need not be sutured. Incision in the flor of the mouth should be sutured with interrupted sutures.