Salivary gland calculus / Sialolithiasis is the most common disease of the salivary glands. Sialolithiasis is most commonly found in the submandibular gland and it’s duct ( Wharton’s duct).
Giant salivary gland stones measuring over 3cm are extremely rare with only scanty reported cases 1. This report describes the case of a patient who had a painless very rare giant Submandibular sialolith visible per orally on the floor of mouth. A 5× 2 cm sized stone was excised.
Sialolithiasis is the most common disease of salivary glands 1. Stones or calculi can be found in all major and minor salivary glands and their ducts. More than 80 % of the calculi are found in Submandibular gland and its duct (more common) 2. Parotid gland accounts for 10% of cases. Remaining cases involve Sublingual and minor salivary glands 2.
Submandibular calculi are most commonly seen in young and middle aged adults with equal affection of both sexes 3. Longer and upward course of the submandibular duct, non- dependent drainage, high calcium and mucin content, more viscid secretion are the factors which favour the formation of submandibular duct stones 3. Bilateral or multiple gland sialolithiasis occurs in less than 3% of cases 4.
Commonly sialoliths measure from 1mm to less than 1cm. Giant salivary gland stones (GSGS) are those stones measuring over 1.5cm and have been rarely reported. GSGS measuring over 3cm are extremely rare with only scanty reported cases 5. The aim of this case report is to highlight a case of a very rare giant sialolith.
A 40 yr old male, farmer by occupation presented to the General Surgery out patient department for a firm, painless, yellowish brown mass in the right side of floor of mouth for 2 yrs. He was a chronic smoker and tobacco chewer with a poor oral hygiene. Medical history of the patient was unremarkable. Patient complained of occasional episodes of mild pain over right jaw during meals.
No palpable swelling or mass was revealed on extra oral examination. In intraoral examination a hard, mobile, non tender, yellowish brown mass was palpable along the anatomical location of the Wharton’s duct. All the teeth were stained. OPG revealed a large calcified mass at that area. With informed consent of the patient, under local anaesthesia, the mass was excised per orally after breaking adhesions using an artery forceps. Patient was discharged on outpatient basis with prescription of oral antibiotics and povidone iodine gargles. Recovery of the patient was complete with no fresh complaints on follow up.
Although large sialoliths have been reported in both salivary glands and their ducts, stones larger than 3cm are rare 5. Mean size is reported as 6 to 9mm 7. A review of literature in 2007 found only 16 reported cases of sialoliths having a size up to 3.5cm 6.
Patient’s generally present with pain, discomfort and swelling before or during meals. 80-90% of Submandibular stones are radio-opaque due to their high content of calcium and magnesium carbonates & phosphates 3 leading to their easy detectibility in standard x-ray films. Other diagnostic methods include Sialography, USG, CT and Scintigraphy. Submandibular stones can be removed surgically through either intraoral or an external approach 7. For stones located entirely in the duct and close to the papillae, intraoral approach is sufficient. Extra oral approach is indicated for intra glandular stones and stones embedded into the hilum of gland.
Newer treatment methods are External lithotripsy and Interventional sialoendoscopy (including wire basket extraction and fibre optic laser lithotripsy) 7.
This case highlights a case of very rare, giant Submandibular duct stone in a patient with poor oral hygiene and neglect for his own health. Patients should be educated regarding the underlying pathology and emphasising the value of adequate hydration and oral hygiene. Once the diagnosis is established attempts at removal by minimally invasive techniques should be considered. However, excision of a salivary stone of such a large size is a rare medical entity.
1.Leung AK, Choi MC, Wagner GA. Multiple sialoliths and a sialolith of unusual size in the submandibular duct. Oral Surg Oral Med Oral Pothol Oral Radiol Eudod.1999;87:331-333.
2.Seifort G, Mann W, Kastenbauer E. Sialolithiasis In: Naumann HH, Helms J, Herberhold C, Kastenbauer E eds. Oto-Rhino-Laryngology, 2[in German]. Stutgart, Germany: Georg Thieme Verlog. 1992.729-32.
3. S.K.Bhattacharya (2011) Short cases in Surgery, 5th edition, New Delhi, India, pp 112-114.
4.Mc Kenna JP, Bostock DJ, Mc Menamin PG. Sialolithiasis. Am Fam physician 1987 ; 36 : 119-25.
5.Ledesma-Montes C, Gorces-Ortiz M, Salcido-Gorcia J, Hernandez-Flores F, Hernandez-Guerrero H. Giant sialolith, case report and review of literature. J Oral Maxillofac Surg.2007;65:128-30.
6.Paul D, Chauhan SR. Salivary megalith with a sialo-cutaneous and a sialo-oral fistula. A case report. J. Laryngol 1995;109:767-9.
7.Zeuk J, Constantinidis J, Al-Kadah B, Iro H. Transoral removal of submandibular stones. Arch Otolaryngol. Head Neck Surg.2001;127:432-6.
Figure 1. Per oral extraction of submandibular calculus.
Figure 2. Cavity on the floor of mouth after calculus extraction.
Figure 3. Extracted calculus.
Figure 4. 5x 2 cm sized calculus.