|Year : 2016 | Volume
| Issue : 2 | Page : 180-183
Imaging features of giant sialolith of submandibular gland: A case report
Komalpreet Kaur, Aravinda Konidena, Gagan Puri, Deepa Jatti
Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana, India
|Date of Submission||01-Aug-2015|
|Date of Acceptance||20-Nov-2016|
|Date of Web Publication||02-Dec-2016|
Dr. Aravinda Konidena
Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Sialolithiasis is an obstructive salivary disease due to salivary stone formation, also known as "meal time syndrome" because of its association with meal times, usually measuring less than 1 cm. However, occasionally giant sialoliths as large as 3 cm have been reported. Here, we report an interesting case of large intraductal sialolith of submandibular salivary gland in an old patient, with relevant radiological investigations and review of literature.
Keywords: Giant sialoliths, sialolithiasis, submandibular gland
|How to cite this article:|
Kaur K, Konidena A, Puri G, Jatti D. Imaging features of giant sialolith of submandibular gland: A case report. J Indian Acad Oral Med Radiol 2016;28:180-3
|How to cite this URL:|
Kaur K, Konidena A, Puri G, Jatti D. Imaging features of giant sialolith of submandibular gland: A case report. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2020 Jan 24];28:180-3. Available from: http://www.jiaomr.in/text.asp?2016/28/2/180/195135
| Introduction|| |
Sialolithiasis is an obstructive salivary disease comprising salivary stone formation, accounting for approximately 50% of major salivary gland diseases. This condition occurs more frequently in male patients, with a peak incidence between the ages of 30 and 60 years.  Sialolithiasis affects the submandibular gland in 80-90%  of cases, parotid gland in 4-10% of cases, and the sublingual gland or minor salivary glands in 1-7%. The increased incidence of sialolithiasis in submandibular gland is due to its more viscous saliva, ascendant, longer duct, sharp-angled duct system and high mineral content in the saliva. 
Majority of sialoliths are formed from phosphate and oxalate salts, and are lesser than 1 cm in size, only occasionally reaching a size greater than 3 cm, when they are termed as giant sialoliths.  Parotid gland stones contain more acidic mineral phases such as brushite and octacalcium phosphate. They contain approximately 70% organic matrix (40% protein, 54% lipids). The organic matrix of submandibular stones, however, is rich in protein and has a high content of lipids.  Here, we report a case of large intraductal sialolith of submandibular gland with striking clinical and radiological features.
| Case Report|| |
A 60-year-old male patient reported with a complaint of swelling in the mouth below the tongue of 2 months duration, which became painful since 1 month. A small swelling was noticed by the patient approximately 2 months back, which was painless in nature and gradually attained the present size. Mild, dull, continuous pain was experienced approximately 1 month back that radiated to the neck and shoulders. The pain was aggravated during meal times and was relieved approximately 30-40 minutes after the meal or use of medication. Medical history of the patient was unremarkable. Intraoral examination revealed a large, well-defined swelling, which was pink in color, on the left side of the floor of mouth, extending from the region of 31 to 36 and measuring approximately 3 × 2 cm in its maximum dimension [Figure 1]. Tongue was slightly elevated due to the swelling. There was no active discharge from the swelling and the surrounding mucosa was not erythematous. On palpation, the swelling was tender, firm, noncompressible, nonfluctuant, nonmobile and no palpable pulsations were present. Patient was completely edentulous with respect to the lower jaw whereas only 12, 13, 14 were present with respect to the upper jaw.
Panoramic radiograph revealed a large, well-defined radiopacity, measuring 2.7 × 1.8 cm in size, on the left parasymphysis region of the mandible [Figure 2]. Cross-sectional topographic radiograph of mandible, revealed a solitary, well-defined, elliptical radiopacity, uniform in density, lying 2 mm away from the body of the mandible [Figure 3]. Ultrasonography of the left submandibular region showed an echogenic mass measuring 0.95 × 1.8 cm, with anechoic area around it. A tortuous and dilated submandibular gland duct was seen [Figure 4]. Color Doppler showed an increase in the vascularity of the submandibular gland [Figure 5]. Hematological investigations were within normal limits.
On the basis of clinical and radiological examination, diagnosis of sialolithiasis of left submandibular gland duct (Wharton's duct) was made and the patient was referred to the Department of Oral surgery. Sialolith was surgically removed by slitting the duct under antibiotic coverage. The sialolith was yellow in color, oval in shape with an irregular surface, measuring 2.5 × 2 cm [Figure 6]. Postoperative sialography was done using Ultravist dye (Iopromide, water soluble contrast agent) that showed pooled contrast media in surgical defect and a sausage string appearance of submandibular gland duct indicating strictures of the duct [Figure 7]. There was no recurrence; patient is under regular follow-up and had remained asymptomatic till date.
| Discussion|| |
Sialolithiasis is the most common obstructive disease of the salivary glands which is found in approximately 65% of the patients with chronic sialadenitis and affect 12 in 1000 adult individuals.  Most cases of submandibular sialoliths are asymptomatic. Pain and swelling may be the classic signs and symptoms, which are more pronounced on anticipation of food due to the obstruction of salivary flow, best known as the "meal-time syndrome," which is often complicated by recurrent bacterial infections, with fever and purulent discharge at the papilla. , Our patient also presented with classic symptoms of pain and swelling, which aggravated during meal times without suppuration.
The exact etiology and pathogenesis of salivary calculi is unknown. They are thought to occur as a result of deposition of calcium salts around an initial organic nidus consisting of altered salivary mucins, bacteria and desquamated epithelial cells. The nidus for parotid stones is formed by inflammatory cells or a foreign body and for submandibular stones it is formed by mucous.  A retrograde theory proposed for sialolithiasis suggests that substances or bacteria within the oral cavity might migrate into the salivary ducts and become the nidus for further calcification. The sialolith, thus, has a central core and a layered periphery. The central core is formed certain organic substances. The second phase consists of the layered deposition of organic and inorganic material. It had also been proposed that an unknown metabolic phenomenon can increase the salivary bicarbonate content, which alters calcium phosphate solubility leading to the precipitation of calcium and phosphate ions. Salivary stagnation, increased alkalinity of saliva, infection or inflammation of the salivary duct or gland, and physical trauma to salivary duct or gland may predispose to calculus formation. 
Salivary calculi are usually small and measure from 1 mm to less than 1 cm. They rarely measure more than 1.5 cm. Mean size is reported to be 6-9 mm. Giant sialoliths are rare and are defined as the size of 3.5 cm or larger.  In the present case, the size of the sialolith was 2.5 × 2 cm, thus, closely approaching the size of a giant sialolith. Large and giant calculi may occasionally perforate the floor of the mouth by ulcerating the duct or may result in a skin fistula by causing a suppurative infection. , Large sialoliths have been frequently reported in the body of salivary glands; they have rarely been described in the salivary ducts, particularly without any complaints from the patients.  In the present case, the large sialolith was intraductal and was symptomatic.
The best radiographic projection for visualizing sialoliths in the submandibular duct and gland is the standard mandibular occlusal view, whereas in the parotid duct and gland, it is best demonstrated by taking a periapical film of the buccal vestibule and exposing them with a reduced exposure. However, radiolucent sialoliths, accounting for approximately 20-40% can be best demonstrated by sialography as filling defects.  Although the diagnosis may be clear, advanced imaging modalities such as ultrasonography, color Doppler, computed tomography, magnetic resonance imaging, scinitigraphy have been used for localizing the sialolith and for assessing the inflammatory changes in the associated gland. Plain radiographs, ultrasonography, color Doppler, and postoperative sialography were employed in our case.
The algorithm for the treatment of sialolithiasis depends upon the location and size of the sialolith. Conservative management for small sialoliths include hydration and application of moist heat. Sialogogues flush stone through increased salivation. Accompanying sialadenitis can be treated by antibiotics. Zenk et al. found that transoral removal is the treatment of choice for submandibular sialoliths, which can be bimanually palpated and can be localized using ultrasonography. Commonly stones present distal to the punctum, are removed using transverse incision, taking care not to injure the lingual nerve. Sialodochoplasty can be performed to remove the submandibular sialoliths which are located close to the orifice of Wharton's duct. 
Minimally invasive interventional procedures such as sialoendoscopy using balloon catheters and small Dormia baskets under fluoroscopic guidance may be used to treat sialolithiasis. The balloon catheter, as the name implies, can be inflated once positioned within a duct to produce dilatation of ductal strictures. The Dormia basket may be used to retrieve mobile ductal salivary stones. Both these procedures are now being used successfully to relieve salivary gland obstruction without the need for surgery. To manage large sialoliths extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal shock wave lithotripsy (EISWL) can also be done because of less damage to the adjacent tissues during the procedure. Carbon dioxide laser has been used because of its advantages of minimal bleeding, less scarring, clear vision and minimal postoperative complications. 
| Conclusion|| |
Imaging modalities play a significant role in the diagnosis and localization of sialoliths, thus affecting the outcome of their management.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]