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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 381-383
Submandibular swelling: Tooth or salivary stone?


1 Department of Specialist Surgical Sciences, ENT Clinic, University of Milan, IRCCS Foundation Ca` Granda Ospedale Maggiore Policlinico, Milan, Italy
2 Department of Surgical, Unit of Oral Pathology and Medicine, Reconstructive and Diagnostic Sciences, University of Milan, IRCCS Foundation Ca` Granda-Ospedale Maggiore Policlinico, Milan, Italy

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Date of Submission21-Feb-2012
Date of Decision22-Jul-2012
Date of Acceptance25-Nov-2012
Date of Web Publication12-Sep-2013
 

   Abstract 

Submandibular swelling is a common clinical disorder of the maxillo-facial region that may be one of the manifestation of several pathologic disorders including sialolithiasis.
A 38-year-old woman experienced a recurrent painful swelling in the right submandibular region for seven years. The symptoms, not always meal-related, gradually became chronic and associated with dysphagia, odynophagia and fever. Ultrasonography of the salivary glands revealed a retained glandular structure and no ductal obstruction or dilatation, and orthopantomography showed the presence of a structure compatible with tooth, but these findings did not correlate with clinical scenario. Only CT dental scan identified the radiological image as a salivary stone.
Sialolithiasis should always be considered in the diagnostic iter of painful submandibular swelling. A careful evaluation of recurrence and characteristics of signs and symptoms associated to the swelling can help in making the correct diagnosis and planning a proper therapeutic strategy.

Keywords: Impacted tooth, sialolithiasis, submandibular swelling

How to cite this article:
Capaccio P, Marciante GA, Gaffuri M, Spadari F. Submandibular swelling: Tooth or salivary stone?. Indian J Dent Res 2013;24:381-3

How to cite this URL:
Capaccio P, Marciante GA, Gaffuri M, Spadari F. Submandibular swelling: Tooth or salivary stone?. Indian J Dent Res [serial online] 2013 [cited 2019 Dec 14];24:381-3. Available from: http://www.ijdr.in/text.asp?2013/24/3/381/118017
Submandibular swelling is a clinical sign of several head and neck disorders; among them sialolithiasis is one of the most common salivary glands' disease in middle-aged patients. [1] Since its clinical and radiological presentation can be very heterogeneous, sialolithiasis should always be considered in the differential diagnosis of submandibular swelling. Although a precise radiological evaluation of size and localization of salivary stones, based on ultrasonography, orthopantomography and dental scan CT, is welcome to plan an appropriate therapeutic strategy, a meticulous evaluation of clinical signs and symptoms is necessary to obtain a proper diagnosis.

We here describe a case of a woman with an atypical history of submandibular swelling after a dental treatment.


   Case Report Top


A 38-year-old woman experienced a recurrent painful swelling in the right submandibular region for seven years. Her medical history was silent except for some dental treatment, and she did not take any drug therapy. At the beginning, the pain was tolerable and occasional, but gradually became chronic and associated with dysphagia, odynophagia and fever. She returned to her dentist, where she underwent ultrasonography (US) and orthopantomography (OPT) in order to assess the real etiology of the swelling. The US revealed a moderate enlargement of the right submandibular gland with a retained glandular structure and no ductal obstruction or dilatation; OPT was diagnostic for a transverse-impacted tooth located in the right lower mandibular branch [Figure 1]. Repeated cycles of anti-inflammatory and antibiotic therapy were then prescribed with partial success.
Figure 1: The orthopantomography revealed the presence of the calcific structure in the right oral floor (black arrow)

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However, as the recurrence of the symptoms (which was occasionally related to meals) aroused the suspicion of a wrong diagnosis, the patient repeated US of the right submandibular gland, which was enlarged in comparison with the contralateral gland, with a retained ultrastructure but no intraparenchymal or duct calcification. This lack of evidence made it necessary to consult an otolaryngologist, and so the patient was referred to the University of Milan's Ear Nose Throat Clinic.

During the physical examination, oropharingoscopy and fiberoptic laryngoscopy showed no irregularities in pharyngeal and laryngeal morphology, and preserved motility. No cervical or submandibular lymph nodes were appreciable. The right submandibular gland was firmer than the left, and glandular massage did not stimulate any salivary secretion from Wharton's duct. Finally, digital palpation of the right region of the oral floor revealed a firm and painless mass with irregular borders attached to the oral floor, with an approximate diameter of 2 cm. Computed tomography (CT dental scan) and another US examination were prescribed. The first revealed a gross calcification (24 × 5 mm) in the right oral floor [Figure 2] and [Figure 3], and US identified an intraparenchymal calcification with a diameter of 3 mm. The patient successfully underwent videoendoscopic-assisted removal of the stone by a transoral approach under local anesthesia [Figure 4], and no complications were observed during and after surgery. At the postoperatory evaluation seven days after surgery, the patient referred a complete and immediate resolution of symptoms, except for a little post-operatory discomfort at the right oral floor, which was quickly vanished.
Figure 2: The CT dental scan (2) showed the peculiar localization and shape of the gross formation hidden by the right mandibular ramus

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Figure 3: The 3D reconstruction showed the gross formation's localization in a multiplanar reconstruction

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Figure 4: Transoral removal of the atypical stone located in the right Wharton's duct

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   Discussion Top


Sialolithiasis is one of the most common diseases affecting the salivary glands, particularly the submandibular glands; sublingual gland stones are very rare, with an incidence of 0.01-1.0%. [2] Traditional and recent etiopathogenetic factors include a reduced salivary flow rate, a change in pH, dehydration, duct anomalies, and the retrograde migration of foods, bacteria or foreign bodies from the oral cavity favoring the stone formation. The clinical presentation may vary from a simple painless swelling to a painful meal-related increase in gland size (the so-called meal-time syndrome) or fever and a purulent discharge from the papilla due to inflammation. Clinical diagnosis is made on the basis of bi-manual manipulation of the gland from a posterior to anterior direction, but imaging, first of all standard radiographs or OPT, is often needed. Although OPT can help clinicians in diagnosing sialoliths in the majority of cases, it can be necessary to perform high-frequency US (which, in experienced hands, can detect more than 90% of >2 mm stones), CT and, more recently, MR sialography, in order to better define a radiopaque solid mass in the pavement of the oral floor associated to swelling of the submandibular region, which can represent the clinical manifestation of other several pathologic conditions, such as displaced tooth, [3] sialophleboliths, [4] presence of a complex odontoma [5] or an osseous choristoma. [6] Finally, the introduction of sialoendoscopy, which permits to explore the duct up to the tertiary duct branching, has improved the diagnosis of microliths not visualized by the traditional radiology. The traditional management of submandibular stones is based on sialolithotomy for stones located in the distal and mid-third of Wharton's duct, and sialadenectomy for deeper stones. The modern management of submandibular stones include sialoendoscopy and interventional radiology with basket retrieval under fluoroscopic imaging; [7] extracorporeal (ESWL) and intracorporeal (ISWL) lithotripsy for stones with a diameter of 3-7 mm; [8] and transoral video-endoscopic assisted surgical removal in the case of large (>7 mm) and impacted stones located between the proximal third of the main duct and the hiloparenchymal region. [9] The use of these minimally invasive and conservative techniques makes it possible to preserve the function of the affected submandibular gland in most cases, and the only remaining indication for sialadenectomy is their failure, or the presence of massive and giant intraparenchymal stones with persistent inflammation. Finally, the first case of the transoral robotic surgical removal of a submandibular stone located in the oral floor has recently been described. [10]


   Conclusion Top


In conclusion, sialolithiasis should always be considered in patients with recurrent painful submandibular swelling. Combination of traditional and modern diagnostic tools together with a precise clinical evaluation helps the clinician to plan a proper therapeutic strategy by means of modern approach such as operative sialoendoscopy.

 
   References Top

1.Epker BN. Obstructive and inflammatory disease of the major salivary glands. Oral Surg Oral Med Oral Pathol 1972;33:2-27.  Back to cited text no. 1
[PUBMED]    
2.Grases F, Santiago C, Simonet BM, Costa-Bauzà A. Sialolithiasis: Mechanism of calculi formation and etiologic factors. Clin Chim Acta 2003;334:131-6.  Back to cited text no. 2
    
3.Huang IY, Wu CW, Worthington P. The displaced lower third molar: A literature review and suggestions for Management. J Oral Maxillofac Surg 2007;65:1186-90.  Back to cited text no. 3
[PUBMED]    
4.Su YX, Liao GQ, Wang L, Liang YJ, Chu M, Zheng GS. Sialoliths or phleboliths? Laryngoscope 2009;119:1344-7.  Back to cited text no. 4
[PUBMED]    
5.Atanasov DT. Sialolithiasis or complex odontoma? Folia Med (Plovdiv) 2003;45:46-7.  Back to cited text no. 5
[PUBMED]    
6.Kamburoglu K, Ozen T, Sençimen M, Ortakoglu K, Günhan O. Osseous choristoma of the submandibular region: Case report. Dentomaxillofac Radiol 2009;38:489-92.  Back to cited text no. 6
    
7.Brown JE, Drage NA, Escudier MP, Wilson RF, McGurk M. Minimally invasive radiologically guided intervention for the treatment of salivary calculi. Cardiovasc Intervent Radiol 2002;25:352-5.  Back to cited text no. 7
[PUBMED]    
8.Nahlieli O, Shacham R, Zaguri A. Combined external lithotripsy and endoscopic techniques for advanced sialolithiasis cases. J Oral Maxillofac Surg 2010;68:347-53.  Back to cited text no. 8
[PUBMED]    
9.Rivera-Serrano CM, Schaitkin BM. Giant bilateral submandibular sialoliths and the role of salivary endoscopy. Laryngoscope 2010;120 (Suppl 4):S135.  Back to cited text no. 9
[PUBMED]    
10.Walvekar RR, Tyler PD, Tammareddi N, Peters G. Robotic-assisted transoral removal of a submandibular megalith. Laryngoscope 2011; 121:534-7.  Back to cited text no. 10
[PUBMED]    

Top
Correspondence Address:
Pasquale Capaccio
Department of Specialist Surgical Sciences, ENT Clinic, University of Milan, IRCCS Foundation Ca` Granda Ospedale Maggiore Policlinico, Milan
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118017

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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