Removing a stone from a salivary duct

Mr Anish Shah describes a technique used for submandibular sialolith removal. A 45-year-old female patient was referred by her GP for investigation of a swelling in the left floor of the mouth area. The patient had first noticed the swelling about two weeks earlier.

The stone was gently lifted from the duct before lavage and suturing
The stone was gently lifted from the duct before lavage and suturing

The patient reported that the swelling in the left submandibular triangle was more apparent during meal times. Her medical history was unremarkable.

Examination revealed a swollen left floor of the mouth area and a hardness of the area was noted on palpation. The left submandibular gland appeared enlarged and tender on palpation. A lower standard occlusal radiograph was taken. This revealed the presence of a radio-opacity in the left floor of mouth area. A diagnosis of left submandibular duct sialolith was made. Arrangements were made for its removal under local anaesthetic.

Intraoral removal
Local anaesthetic was infiltrated around the area. Care was taken to ensure the stone did not 'slip' further proximally into the duct.

A linear incision through the overlying mucosa was made. Blunt dissection was used to locate the duct and this was incised to reveal the stone. The stone was gently lifted out of the duct and the gland thoroughly massaged to allow exudation of any mucus or pus build up.

Lavage of the area was followed by sutures to close. Co-amoxidar 375mg was prescribed for five days post-operatively.

The patient was reviewed a month later. The intraoral site had healed very well and the patient's previous left submandibular gland swelling had reduced considerably.

Discussion
Sialoliths present in a salivary gland or duct account for 50 per cent of major salivary gland disease.

Most salivary stones occur in the submandibular gland (63-94 per cent) and the remainder in the parotid. Salivary calculi are usually unilateral and are not a cause of dry mouth. They are round or ovoid and yellowish in colour.

Stones in the anterior portion of the duct can be easily removed via an intraoral approach. Care should be taken to avoid the lingual nerve, which in this area is deeper than the duct. With this technique it is recommended that antibiotics are prescribed post-operatively to reduce the chances of infection in a potential 'danger' area.

A variety of methods have been suggested for sialolith treatment. These include litho-tripsy, basket retrieval to remove the stone or fragments, and the use of sialendoscopy in negotiation of ducts.

These treatments are usually carried out at specialist centres, such as the ENT department at Guy's and St Thomas' Hospital, London. The development of techniques in these centres has allowed approximately 70 per cent of sialoliths to be treated without the need for formal surgical gland removal.1

Treatment largely depends on symptoms and stone location. A lack of symptoms often means the patient is unaware of the presenting stone and intervention can be avoided.

Conclusion
There are a variety of methods used in the treatment of salivary gland stones. The treatment will depend on symptoms and the location of the stone.

This case report highlights a relatively simple technique that can be used in the removal of anterior submandibular duct stones under local anaesthetic.

  • Mr Shah is a specialist oral surgeon in London

Reference

1. McGurk M, Escudier M P, Brown J E. Modern management of salivary calculi. Br J Surg 2005; 92: 107-12.

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