Sialolithiasis: A Case Report

INTRODUCTION

Sialolithiasis refers to the formation of hard, stone-like deposits within the ducts of the salivary glands, which may vary in size from small to large, and it is one of the most common salivary gland disorders after mumps. Salivary stones most commonly occur in individuals between 40 and 50 years of age and are usually located within the ducts of the major and minor salivary glands. Although the exact etiology is not completely understood, factors such as increased salivary pH, increased viscosity of saliva, and mucus-rich secretions are thought to contribute to stone formation.^[1]

The principal clinical features of sialolithiasis include pain and swelling in the region of the parotid or submandibular ducts. Only about 10% of submandibular stones are located entirely within the gland itself. The submandibular duct is long and narrow, and salivary flow through it is relatively slow due to the anatomical position of the mylohyoid muscle, predisposing it to obstruction and increased intraglandular pressure. Persistent elevation of pressure may lead to connective tissue proliferation and subsequent damage to or loss of the saliva-secreting acinar cells within the gland.^[2]

Despite the availability of more advanced diagnostic techniques, occlusal radiographs remain a useful tool for the detection of salivary calculi. Small stones can often be managed conservatively, whereas larger calculi usually require surgical removal by sialolithotomy, commonly performed with endoscopic assistance. Retrieval instruments such as the Dormia handbasket and multiple flexible wires are used for stone removal, and antibiotics are frequently prescribed as part of the treatment regimen. In cases of partial obstruction, salivary flow may be reduced without producing significant changes in the oral cavity.^[3] Accurate diagnosis of sialolithiasis requires a detailed medical history and appropriate imaging studies to localize calcific deposits and support the clinical findings. This case report aims to emphasize the etiological factors and outline the available medical and surgical treatment options for submandibular sialolithiasis.

CASE HISTORY

A 34-year-old male reported to our Oral Medicine & Radiology department with a chief complaint of recurrent episodes of pain and pus discharge in the right side of the floor of the mouth for 16 days. The patient had no relevant medical or family history. Extraoral examination was overall non-significant. Intraoral hard tissue revealed generalized recession and generalized attrition. Intraoral examination revealed swelling on the right side of the floor of the mouth, ~1 cm in size. On bimanual palpation, we observe noticeable pus discharge from the right side submandibular gland orifice. Mandibular occlusal radiograph revealed a radiopaque mass, which was single, circular in shape, in the right submandibular area on the occlusal radiograph. On USG of the right submandibular gland, the parenchyma appears thin. There is an echogenic calculus of size 4.5 mm noted at the opening of the proximal end of the submandibular duct within the gland parenchyma, causing obstruction of the gland, suggestive of right intraparenchymal sialothiasis [Figure-1,2,3,4].

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Figure 1:

Extraoral photograph

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Figure 2:

Intraoral photograph

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Figure 3:

Maxillary occlusal radiograph

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Figure 4:

Excised calculi

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All preoperative evaluations were within normal ranges, and the patient's antibiotic therapy was initiated. Utilizing local anesthesia, a surgical incision was made in the floor of the mouth. The duct was opened, and the sialolith was surgically removed as a single piece. The stone measured 4.5 mm, weighing 0.05 g on an electronic scale. Sutures were applied to close the incision site. Patient came for follow-up and suture removal with complete healing [Figure-5].

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Figure 5:

15^th day follow-up photograph after suture removal

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DISCUSSION

Sialolithiasis is a common disorder of the salivary glands, characterized by the presence of a calculus within the gland or its ductal system, resulting in obstruction of salivary flow.^[4] Salivary stones occur more frequently in the submandibular gland (84%) than in the parotid gland (13%). The majority of submandibular sialoliths are located in Wharton’s duct (90%), whereas parotid stones are more commonly found within the gland parenchyma.^[5]

Clinically, sialolithiasis typically presents with pain and swelling during meals, which may last for several hours, and symptoms can persist for weeks or even months. These manifestations occur due to obstruction of salivary outflow, leading to accumulation of saliva and increased intraglandular pressure. In some cases, salivary stones may remain asymptomatic and are incidentally detected on radiographic examination.^[5]

Several imaging modalities are useful for diagnosis and treatment planning. Intraoral occlusal and extraoral panoramic radiographs are commonly used; however, extraoral radiographs may fail to detect smaller stones because of overlapping anatomical structures. In such situations, computed tomography (CT) and cone-beam computed tomography (CBCT) can be advantageous. Ultrasonography is another useful diagnostic tool and is capable of detecting stones measuring 2 mm or more.^[4]

Sialendoscopy is a minimally invasive technique that allows direct visualization of the salivary ductal system and is usually performed under general anesthesia. A small-diameter endoscope, ~0.6 mm, is introduced into the duct after dilation of the ductal orifice using specialized instruments. The endoscope contains an irrigation channel that permits flushing of the duct with saline or anti-inflammatory solutions, which enhances ductal visualization and may also provide therapeutic benefits.^[5]

Management of sialolithiasis includes both non-invasive and invasive treatment options. Conservative measures consist of gland massage after meals, adequate hydration with approximately 1.5 liters of water per day, and the use of sialogogues to stimulate salivary flow. Invasive treatment options include extracorporeal shockwave lithotripsy (ESWL), sialendoscopy, and surgical intervention. ESWL is particularly useful for stones that are not clinically palpable or are identified during endoscopic evaluation.^[6]

Surgical management is primarily ablative in nature. For stones that are clinically palpable or located in the prehilar region of the gland, a transoral approach is generally preferred. During this procedure, care must be taken to avoid injury to the lingual nerve by limiting dissection beyond the first mandibular molar. It is also important to recognize that surgical treatment may result in a visible cervical scar and carries a risk of injury to adjacent cranial nerves, including the mandibular division of the trigeminal nerve (V3), the facial nerve (VII), and the hypoglossal nerve (XII).^[6]

CONCLUSION

Sialolithiasis, particularly in the submandibular gland, can cause significant discomfort and requires timely intervention. Surgical removal is effective for large, inaccessible stones. A thorough history taking and complete examination are necessary to support the clinical diagnosis, and it can be diagnosed with an X-ray views alone. Other modalities include CBCT, CT, Ultrasonography, Sialendoscopy. Infection is suspected in the presence of gland enlargement and sialolithiasis. Early diagnosis and prompt management are crucial to prevent glandular damage and ensure complete recovery.