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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 4  |  Page : 437-440

Giant submandibular sialolith in an old female patient: A case report and review of literature


Department of Oral Medicine and Radiology, Rishiraj College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Date of Submission30-Nov-2015
Date of Acceptance01-Feb-2017
Date of Web Publication21-Feb-2017

Correspondence Address:
Dr. Thimmarasa V Bhovi
Department of Oral Medicine and Radiology, Rishiraj College of Dental Sciences and Research Centre, Bhopal - 426 036, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_242_15

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   Abstract 

Sialolithiasis or salivary gland duct calculus or salivary stones are the most common pathologies of the salivary gland. Sialolithiasis accounts for more than 50% of the major salivary gland diseases. Sialoliths are deposits obstructing the ducts of major or minor salivary glands or its parenchyma. Salivary stones larger than 15 mm are classified as giant sialoliths. Giant sialoliths measuring 35 mm or more are extremely rare, with approximately 18 cases published in literature all reported in male patients. The aim of this article is to present a case of a giant sialolith occurring in an old female patient and to communicate the results of a literature search on giant sialoliths.

Keywords: Giant sialolith, salivary gland, Wharton's duct


How to cite this article:
Bhovi TV, Jaju PP, Ojha S, Bhadouria P. Giant submandibular sialolith in an old female patient: A case report and review of literature. J Indian Acad Oral Med Radiol 2016;28:437-40

How to cite this URL:
Bhovi TV, Jaju PP, Ojha S, Bhadouria P. Giant submandibular sialolith in an old female patient: A case report and review of literature. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2019 Jul 19];28:437-40. Available from: http://www.jiaomr.in/text.asp?2016/28/4/437/200634


   Introduction Top


Sialoliths are calcified matter seen in the salivary gland parenchyma or its duct. It accounts for more than 50% of the salivary gland diseases, with 12 out of 1000 persons in the adult population being affected every year; thus, it is the most common cause of acute and chronic infections.[1] Approximately 80% of all reported cases occur in the submandibular gland or its duct, 6% in the parotid gland, and 2% in the sublingual gland or minor salivary glands.[2] Clinically, they are round or ovoid, rough or smooth, and of a yellowish color. They develop because of the deposition of mineral salts around a nidus of bacteria, desquamated cells, or mucus. Sialoliths are composed of organic and inorganic substances, mainly calcium phosphate, and smaller amounts of carbonates in the form of hydroxyapatite. Submandibular stones are made up of 82% inorganic and 18% organic material, whereas parotid stones are composed of 49% inorganic and 51% organic material.[1]

Commonly, sialoliths measure 5–10 mm in size, and stones over 10 mm can be reported to be sialoliths of unusual size. They rarely measure more than 15 mm. Giant sialoliths measuring 35 mm or more are rare, with only 18 cases published in literature [Table 1].[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] Ninety-five percent of the giant sialoliths reported were in the submandibular gland, all occurring in male patients. We report the first case of a giant sailolith measuring approximately 35mm, in an old female patient along with a review of literature.
Table 1: Giant sialoliths reported in literature

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   Case History Top


A 50-year-old female patient reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling on the right side of the floor of the mouth of more than 1 year duration. Patient's medical history was noncontributory. Extraoral examination revealed a diffuse swelling in the right submandibular region with no other significant findings [Figure 1]. Intraoral examination revealed a large, firm-to-hard in consistency, nontender swelling on the right floor of the mouth with a hard, yellowish white structure protruding from the right Wharton's duct orifice [Figure 2]. The mucosa over the swelling was normal. There was no history of pain and/or swelling aggravating during meals or discharge of pus.
Figure 1: Patient profile photograph showing right submandibular swelling

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Figure 2: Intraoral photograph showing swelling with a hard structure protruding from the right Wharton's duct

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On the basis of clinical examination, a provisional diagnosis of sialolithiasis of the right submandibular gland was considered with a differential diagnosis of chronic submandibular sialdenitis, foreign body and lymph node calcification. We also considered a differential diagnoses of ranula and dermoid cyst. The color of the mucosa over the swelling and consistency were not favorable for ranula, which appears bluish and soft in consistency. Dermoid cyst is a developmental swelling with yellowish mucosa.

Mandibular occlusal radiograph and orthopantomograph revealed a well-defined, large radiopaque mass medial to the right body of the mandible along the course of Wharton's duct [Figure 3] and [Figure 4]. A diagnosis of right submandibular duct sialolith was confirmed. After administration of local anesthesia, a giant sialolith was removed in a minimally invasive manner via intraoral sialolithotomy and sialodochoplasty [Figure 5]. The sialolith was measuring approximately 35 mm (including the bent portion), weighed approximately 13 g, and was of yellow-to-white in color [Figure 6]. After 6 months of follow up, the patient remained asymptomatic with satisfactory glandular function and normal, undisturbed salivary flow.
Figure 3: Mandibular occlusal radiograph showing a large radiopaque mass on the right side of the floor of mouth

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Figure 4: Orthopantomograph showing a large radiopaque mass on the right side of the edentulous ridge

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Figure 5: Postoperative photograph

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Figure 6: Large sialolith after removal measuring 35 × 10 mm (including bent portion)

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   Discussion Top


Salivary gland calculi are a common occurrence in the salivary glands. It is twice as common in males than females.[1],[14],[16] Most commonly, it involves the major salivary glands. Its estimated frequency is 1.2% in the adult population, with slight male predominance.[16] Most of the sialoliths are reported in the submandibular salivary gland with few incidences in the parotid and sublingual glands. Submandibular salivary gland is commonly affected because of the longer and wider diameter excretory duct, salivary flow against gravity, alkaline pH and higher content of mucin proteins, calcium, and phosphate.[17] Sialolith formation can occur in two phases, namely, the central core and a layered periphery phase. The first central core phase is formed by the precipitation of salts, which are bound by certain organic substances such as various carbohydrates and amino acids. The second layered periphery phase consists of layered deposition of organic and inorganic material. Parotid stones are thought to form most often around a nidus of inflammatory cells or a foreign body whereas submandibular stones are thought to form around a nidus of mucous.[18] Peak incidence occurs between the ages of 20 and 60 years, and is uncommon in children.[14],[19]

Giant sialoliths are a rare entity with sizes varying from 3.5 to 7 cm, mostly in male patients [Table 1], however, in the present case, the reported patient was a female. The giant sialolith of the submandibular duct measuring 35 mm or more in a female patient, to the best of our knowledge, is the first reported case in literature. With the exception of one case, all the giant sialoliths were located in the submandibular gland (94.4%), and only an isolated case was found within the Stensen's duct of the parotid salivary gland. Large calculi are also known by their weights.[20],[21] Weight of the giant sialoliths was not communicated in all these previously reported cases, however, according to the reported data, they can be very light specimens (4.2 g) or can attain a heavy weight (33 g), as can be seen in our case with a reported weight of 13 g.

Several factors contribute to the development of sialolith in the submandibular gland. The saliva from the submandibular gland has a high content of mucin and flows uphill in a wider and longer duct as compared to that in the parotid gland. Stenson's duct (parotid gland) is narrow and the serous saliva from the parotid gland flows downhill. In addition, the saliva secreted by the submandibular gland is alkaline and has a high content of calcium and phosphate, which promotes stone formation.[1],[16],[18],[20]

Imaging studies are very useful for diagnosing sialoliths. To visualize the radiopaque stones in the submandibular duct, the best view is a standard mandibular occlusal radiograph. Radiopacity is not a consistent feature in most of the submandibular stones, and hence, sialography, ultrasound, computed tomography, and magnetic resonance sialography may be required for locating the stone.[15],[21] Different treatment options may be selected according to the size and location of the sialolith. Small stones can be milked out through the ductal orifices using bimanual palpation. If a stone is large, piezoelectrical extracorporal shock wave lithotripsy or surgical removal of the stone or gland may be required.[22]


   Conclusion Top


Sialoliths can obstruct the secretary duct, resulting in a chronic retrograde infection because of a decrease in salivary flow. Asymptomatic giant sialolith of remarkable size poses both diagnostic and therapeutic challenges for the clinician. We reported a rare case of giant submandibular gland sialolith in a female patient, which was removed under local anesthesia. No recurrence was observed after 6 months of intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors acknowledge Dr. Vedant Phahalganj and Dr. Deepashri Kambalimath, Department of Oral Surgery, Rishiraj Dental College, Bhopal, for assisting in the surgical removal of the intact sialolith.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Siddiqui SJ. Sialolithiasis: An unusually large submandibular salivary stone. Br Dent J 2002;193:89-91.  Back to cited text no. 1
    
2.
Gupta A, Ratan D, Gupta R. Gaint sialoliths of submandibular gland duct: Report of two cases with unusual shape. Contemp Clin Dent 2013;4:78-80.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Meyers H. Large calculus in submaxillary gland. Dent Digest 1942;48:420.  Back to cited text no. 3
    
4.
Mustard TA. Calculus of unusual size in Wharton's duct. Br Dent J 1945;79:129.  Back to cited text no. 4
    
5.
Allen NE. A sialolith within the submaxillary duct and gland: Report of a case. J Oral Surg 1956;14:65.  Back to cited text no. 5
    
6.
Cavina C, Santoli A. Some cases of salivary calculi of particular interest. Minerva Stomatol 1965;14:90.  Back to cited text no. 6
    
7.
Hoggins GS. Large calcified mass in the submaxillary gland. Oral Surg Oral Med Oral Pathol 1968;25:679.  Back to cited text no. 7
    
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Rust TA, Messerly CD. Oddities of salivary calculi. Oral Surg Oral Med Oral Pathol 1969;28:862.  Back to cited text no. 8
    
9.
Raksin SZ, Gould SM, William AC. Submandibular gland sialolith of unusual size and shape. J Oral Surg 1975;33:142.  Back to cited text no. 9
    
10.
Isacsson G, Nils-Erik P. The gigantiform salivary calculus. Int J Oral Surg 1982;11:135.  Back to cited text no. 10
    
11.
Tinsley G. An extraordinarily large asymptomatic submandibular salivary calculus. Br Dent J 1989;166:199.  Back to cited text no. 11
    
12.
Hubar JS, Guggenheimer J, Evan M. Megalith. Oral Surg Oral Med Oral Pathol 1990;70:245.  Back to cited text no. 12
    
13.
Akin I, Esmer M. A submandibular sialolith of unusual size. J Otolaryngol 1991;20:123.  Back to cited text no. 13
    
14.
Paul D, Chauhan MS. Salivary megalith with a sialo-cutaneous and sialo-oral fistula: A case report. J Laryngol Otol 1995;109:767.  Back to cited text no. 14
    
15.
Bodner L. Giant salivary gland calculi: Diagnostic imaging and surgical management. Oral Surg Oral Med Oral Pathol Radiol Endod 2002;94:320.  Back to cited text no. 15
    
16.
Ledesma-Montes C, Garcés-Ortíz M, Salcido-García JF, Hernández-Flores F, Hernández-Guerrero JC. Giant sialolith: Case report and review of literature. J Oral Maxillofac Surg 2007;65:128-30.  Back to cited text no. 16
    
17.
Rai M, Burman R. Giant submandibular sialolith of remarkable size in the comma area of Wharton's duct: A case report. J Oral Maxillofac Surg 2009;67:1329-32.  Back to cited text no. 17
    
18.
Babu L, Jain MK. Giant submandibular sialolith. A case report and review of literature. Int J Head Neck Surg 2001;2:154-7.  Back to cited text no. 18
    
19.
Chandra SJ. Submandibular sialoithiasis: Analysis of 4 case reports. JIMSA 2010;2:97-8.  Back to cited text no. 19
    
20.
Zakaria MAK. Giant calculi of the submandibular salivary gland. Br J Oral Surg 1981;19:230.  Back to cited text no. 20
    
21.
Brusati R, Fiamminghi L. Large calculus of the submandibular gland: Report of case. J Oral Surg 1973;31:710.  Back to cited text no. 21
    
22.
McGurk M, Escudier MP, Brown JE. Modern management of salivary calculi. Br J Surg 2005;92:107-12.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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